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Defilippo A, Veltri P, Lió P, Guzzi PH. Leveraging graph neural networks for supporting automatic triage of patients. Sci Rep 2024; 14:12548. [PMID: 38822012 PMCID: PMC11143315 DOI: 10.1038/s41598-024-63376-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/28/2024] [Indexed: 06/02/2024] Open
Abstract
Patient triage is crucial in emergency departments, ensuring timely and appropriate care based on correctly evaluating the emergency grade of patient conditions. Triage methods are generally performed by human operator based on her own experience and information that are gathered from the patient management process. Thus, it is a process that can generate errors in emergency-level associations. Recently, Traditional triage methods heavily rely on human decisions, which can be subjective and prone to errors. A growing interest has recently been focused on leveraging artificial intelligence (AI) to develop algorithms to maximize information gathering and minimize errors in patient triage processing. We define and implement an AI-based module to manage patients' emergency code assignments in emergency departments. It uses historical data from the emergency department to train the medical decision-making process. Data containing relevant patient information, such as vital signs, symptoms, and medical history, accurately classify patients into triage categories. Experimental results demonstrate that the proposed algorithm achieved high accuracy outperforming traditional triage methods. By using the proposed method, we claim that healthcare professionals can predict severity index to guide patient management processing and resource allocation.
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Affiliation(s)
- Annamaria Defilippo
- Dept. Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Pierangelo Veltri
- DIMES Department of Informatics, Modeling, Electronics and Systems, UNICAL, Rende, Cosenza, Italy
| | - Pietro Lió
- Department of Computer Science and Technology, Cambridge University, Cambridge, UK
| | - Pietro Hiram Guzzi
- Dept. Medical and Surgical Sciences, Magna Graecia University of Catanzaro, Catanzaro, Italy.
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Ingielewicz A, Rychlik P, Sieminski M. Drinking from the Holy Grail-Does a Perfect Triage System Exist? And Where to Look for It? J Pers Med 2024; 14:590. [PMID: 38929811 PMCID: PMC11204574 DOI: 10.3390/jpm14060590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
The Emergency Department (ED) is a facility meant to treat patients in need of medical assistance. The choice of triage system hugely impactsed the organization of any given ED and it is important to analyze them for their effectiveness. The goal of this review is to briefly describe selected triage systems in an attempt to find the perfect one. Papers published in PubMed from 1990 to 2022 were reviewed. The following terms were used for comparison: "ED" and "triage system". The papers contained data on the design and function of the triage system, its validation, and its performance. After studies comparing the distinct means of patient selection were reviewed, they were meant to be classified as either flawed or non-ideal. The validity of all the comparable segregation systems was similar. A possible solution would be to search for a new, measurable parameter for a more accurate risk estimation, which could be a game changer in terms of triage assessment. The dynamic development of artificial intelligence (AI) technologies has recently been observed. The authors of this study believe that the future segregation system should be a combination of the experience and intuition of trained healthcare professionals and modern technology (artificial intelligence).
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Affiliation(s)
- Anna Ingielewicz
- Department of Emergency Medicine, Faculty of Health Science, Medical University of Gdansk, Mariana Smoluchowskiego Street 17, 80-214 Gdansk, Poland;
- Emergency Department, Copernicus Hospital, Nowe Ogrody Street 1-6, 80-203 Gdansk, Poland
| | - Piotr Rychlik
- Emergency Department, Copernicus Hospital, Nowe Ogrody Street 1-6, 80-203 Gdansk, Poland
| | - Mariusz Sieminski
- Department of Emergency Medicine, Faculty of Health Science, Medical University of Gdansk, Mariana Smoluchowskiego Street 17, 80-214 Gdansk, Poland;
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von Rhein M, Chaouch A, Oros V, Manzano S, Gualco G, Sidler M, Laasner U, Dey M, Dratva J, Seiler M. The effect of the COVID-19 pandemic on pediatric emergency department utilization in three regions in Switzerland. Int J Emerg Med 2024; 17:64. [PMID: 38755579 PMCID: PMC11097595 DOI: 10.1186/s12245-024-00640-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 05/04/2024] [Indexed: 05/18/2024] Open
Abstract
PURPOSE The COVID-19 pandemic was associated with a decrease in emergency department (ED) visits. However, contradictory, and sparse data regarding children could not yet answer the question, how pediatric ED utilization evolved throughout the pandemic. Our objectives were to investigate the impact of the pandemic in three language regions of Switzerland by analyzing trends over time, describe regional differences, and address implications for future healthcare. METHODS We conducted a retrospective, longitudinal cohort study at three Swiss tertiary pediatric EDs (March 1st, 2018-February 28th, 2022), analyzing the numbers of ED visits (including patients` age, triage categories, and urgent vs. non-urgent cases). The impact of COVID-19 related non-pharmaceutical interventions (NPIs) on pediatric ED utilization was assessed by interrupted time series (ITS) modelling. RESULTS Based on 304'438 ED visits, we found a drop of nearly 50% at the onset of NPIs, followed by a gradual recovery. This primarily affected children 0-4 years, and both non-urgent and urgent cases. However, the decline in urgent visits appeared to be more pronounced in two centers compared to a third, where also hospitalization rates did not decrease significantly during the pandemic. A subgroup analysis showed a significant decrease in respiratory and gastrointestinal diseases, and an increase in the proportion of trauma patients during the pandemic. CONCLUSIONS The COVID-19 pandemic had substantial effects on number and reasons for pediatric ED visits, particularly among children 0-4 years. Despite equal regulatory conditions, the utilization dynamics varied markedly between the three regions, highlighting the multifactorial modification of pediatric ED utilization during the pandemic. Furthermore, future policy decisions should take regional differences into account.
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Affiliation(s)
- Michael von Rhein
- Child Development Center, University Children`s Hospital Zurich, University of Zurich, Zurich, Switzerland.
| | - Aziz Chaouch
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Vivian Oros
- University Children`S Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sergio Manzano
- Pediatric Emergency Department, Geneva University Hospitals, University of Geneva, Geneva, Switzerland
| | - Gianluca Gualco
- Pediatric Emergency Departement, Clinics of Pediatrics, Institute of Pediatrics of Southern Switzerland, EOC, Bellinzona, Switzerland
| | | | | | - Michelle Dey
- School of Health Science, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
| | - Julia Dratva
- School of Health Science, ZHAW Zurich University of Applied Sciences, Winterthur, Switzerland
- Medical Faculty, University of Basel, Basel, Switzerland
| | - Michelle Seiler
- Pediatric Emergency Department, University Children`S Hospital Zurich, University of Zurich, Zurich, Switzerland
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Hong M, Devlin RA, Zaric GS, Thind A, Sarma S. Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:363-377. [PMID: 37154832 DOI: 10.1007/s10198-023-01591-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 04/19/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION It is well-known that the way physicians are remunerated can affect delivery of health care services to the population. Fee-for-service (FFS) generally leads to oversupply of services, while capitation leads to undersupply of services. However, little evidence exists on the link between remuneration and emergency department (ED) visits. We fill this gap using two popular blended models introduced in Ontario, Canada: the Family Health Group (FHG), an enhanced/blended FFS model, and Family Health Organization (FHO), a blended capitation model. We compare primary care services and rates of emergency department ED visits between these two models. We also evaluate whether these outcomes vary by regular- and after-hours, and patient morbidity status. METHODS Physicians practicing in an FHG or FHO between April 2012 and March 2017 and their enrolled adult patients were included for analyses. The covariate-balancing propensity score weighting method was used to remove the influence of observable confounding and negative-binomial and linear regression models were used to evaluate the rates of primary care services, ED visits, and the dollar value of primary care services delivered between FHGs and FHOs. Visits were stratified as regular- and after-hours. Patients were stratified into three morbidity groups: non-morbid, single-morbid, and multimorbid (two or more chronic conditions). RESULTS 6184 physicians and their patients were available for analysis. Compared to FHG physicians, FHO physicians delivered 14% (95% CI 13%, 15%) fewer primary care services per patient per year, with 27% fewer services during after-hours (95% CI 25%, 29%). Patients enrolled to FHO physicians made 27% more less-urgent (95% CI 23%, 31%) and 10% more urgent (95% CI 7%, 13%) ED visits per patient per year, with no difference in very-urgent ED visits. Differences in the pattern of ED visits were similar during regular- and after-hours. Although FHO physicians provided fewer services, multimorbid patients in FHOs made fewer very-urgent and urgent ED visits, with no difference in less-urgent ED visits. CONCLUSION Primary care physicians practicing in Ontario's blended capitation model provide fewer primary care services compared to those practicing in a blended FFS model. Although the overall rate of ED visits was higher among patients enrolled to FHO physicians, multimorbid patients of FHO physicians make fewer urgent and very-urgent ED visits.
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Affiliation(s)
- Michael Hong
- Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, ON, Canada
| | - Gregory S Zaric
- Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Ivey Business School, Western University, London, ON, Canada
| | - Amardeep Thind
- Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
- Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Western Centre for Public Health and Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada.
- Institute for Clinical Evaluative Sciences (ICES), Toronto, ON, Canada.
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Tillmann BW, Nathens AB, Guttman MP, Pequeno P, Scales DC, Pechlivanoglou P, Haas B. The impact of referring hospital resources on interfacility overtriage: A population-based analysis. Injury 2024; 55:111332. [PMID: 38281350 DOI: 10.1016/j.injury.2024.111332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 12/13/2023] [Accepted: 01/13/2024] [Indexed: 01/30/2024]
Abstract
BACKGROUND Nearly half of patients transferred from non-trauma to trauma centres have minor injuries. The transfer of patients with minor injuries to trauma centres is not associated with any known patient benefit and represents an opportunity to reduce healthcare costs and improve patient experience. In this study, we evaluated the relationship between hospital resources and overtriage, with the objective of identifying targets for system-level intervention. METHODS We conducted a population-based cohort study of adults, age ≥ 16, presenting with minor injuries to non-trauma centres in Ontario, Canada (2009-2020). The primary outcome was overtriage, defined as transfer to a trauma centre. Hierarchical logistic regression was used to evaluate the association between hospital resources and a patient's likelihood of being overtriaged, adjusting for case-mix. RESULTS amongst 165,302 patients with minor injuries, 15,641 (9.5 %) were transferred to a trauma centre (overtriage). Presence of a CT scanner, surgical support, or intensive care unit had no impact on a patient's likelihood of overtriage. Relative to community hospitals, presentation to a teaching hospital was independently associated with greater odds of overtriage (OR 2.97, 95 % CI: 1.26-7.00). Accounting for case-mix and resources, the median difference in a patient's odds of overtriage varied 3.7-fold across non-trauma centres (MOR 3.76). CONCLUSIONS There is significant variability in overtriage across non-trauma centres, even after adjusting for case-mix and hospital resources. These finding suggests that some centres have developed processes to minimize overtriage independent of available resources. Broad implementation of these processes may represent an opportunity for system-wide quality improvement.
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Affiliation(s)
- Bourke W Tillmann
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, Division of Respirology and Critical Care Medicine, University Health Network, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
| | - Avery B Nathens
- Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, University of Toronto, Toronto, Ontario, Canada
| | - Matthew P Guttman
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Damon C Scales
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Petros Pechlivanoglou
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Toronto Health Economic and Technology Assessment Collaborative, Toronto, Ontario, Canada; The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Barbara Haas
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada; Sunnybrook Research Institute, Toronto, Ontario, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Surgery, University of Toronto, Toronto, Ontario, Canada; ICES, University of Toronto, Toronto, Ontario, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Kalan L, Chahine RA, Lasfer C. The Effectiveness and Relevance of the Canadian Triage System at Times of Overcrowding in the Emergency Department of a Private Tertiary Hospital: A United Arab Emirates (UAE) Study. Cureus 2024; 16:e52921. [PMID: 38406095 PMCID: PMC10894025 DOI: 10.7759/cureus.52921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2024] [Indexed: 02/27/2024] Open
Abstract
OBJECTIVE A systematic and straightforward triage system is crucial for the proper and timely care of patients within the emergency department (ED). This study unfolds a detailed understanding of the impact of the Canadian Triage and Acuity Scale (CTAS) on patient care and resource allocation in a private tertiary hospital. To the best of our knowledge, this is the only article studying the impact of the CTAS in one of the private hospitals in the United Arab Emirates (UAE) to achieve triage optimisation strategies. There is scope for further research in both public and private hospitals in the UAE. A triage system not only helps healthcare professionals prioritise cases conveniently but also guides patients to the most suitable area for a consultation. As a general rule, EDs follow an algorithm for the purpose of triage, and the aim of our study is to assess one such five-level triage system, CTAS, for its effectiveness and relevance during overcrowding in a UAE ED. METHOD Within a period of approximately three weeks, a total of 351 CTAS-triaged patients were included in a prospective observational study during peak hours (17:00-22:00) of an ED in the UAE. The CTAS app was used as the triage tool to assess relevance, in terms of patient waiting times, resource allocation, and urgency level distribution, to the Canadian scale. All patients presenting to the ED were included with no exclusion criteria. The relationship between urgency level, duration of visit, and resources used was assessed, and the department's triage results were compared with those of the CTAS app. RESULTS Our sample showed a female (187; 53.3%) and adult preponderance (215; 61.3%) with most of the adult patients aged between 30 and 40 (96; 44.65%). 41.5% (145) of the triage was mismatched between the department and the CTAS app with 115 (79.3%) cases of under-triaging and 30 (20.7%) cases of over-triaging. There was a statistically significant difference (p=0.004) between average waiting times across triage categories 4 and 5 with the former category patients waiting for a longer period of time. Cohen's kappa showed moderate inter-relatability (k=0.42). The average utilisation costs per triage category showed a positive correlation with the urgency level for CTAS (Pearson's r=0.59); however, the costs declined as the urgency level rose for the department. CONCLUSIONS The high compliance rate demonstrates that the CTAS can be applicable to institutions outside of Canada. The categorisation of patients by the CTAS and their resource allocation were more accurate than the standard triage proving its effectiveness as a triage tool. Lack of synchronisation among the triage nurses and inadequate triage training are the most plausible reasons for this comparison. The recommended "time to be seen by a physician" was achievable in our ED, and that, along with the expected relationship between CTAS and resource utilisation, can be seen as valid indicators for a quality triage system for use in the UAE.
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Affiliation(s)
- Laila Kalan
- Trauma and Orthopaedics, University Hospitals Birmingham National Health Service (NHS) Foundation Trust, Birmingham, GBR
| | - Racha A Chahine
- Quality and Risk Management, Fakeeh University Hospital, Dubai, ARE
| | - Chafika Lasfer
- Emergency Medicine, Fakeeh University Hospital, Dubai, ARE
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Choi Y, Lee DH, Oh J. Epidemiology and clinical characteristics of trauma in older patients transferred from long-term care hospitals to emergency departments: A nationwide retrospective study in South Korea. Arch Gerontol Geriatr 2023; 115:105212. [PMID: 37774489 DOI: 10.1016/j.archger.2023.105212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 09/01/2023] [Accepted: 09/23/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND South Korea's aging population had leg to an increased number of long-term care hospitals (LTCHs), and increased transfer of older patients to emergency departments (EDs). This study investigated the epidemiological and injury profiles of LTCH patients aged ≥65 who were transferred from LTCHs to EDs due to trauma. METHOD This retrospective study conducted between January 2014 and December 2019 in South Korea utilized data from the National Emergency Department Information System. The requirement for informed consent was waived by the IRB due to the retrospective nature of the study. Patient information was anonymized prior to analysis. RESULTS Of the 1,472,006 trauma cases aged ≥65, 14,469 came from LTCHs. Outcomes varied: 44.1% were discharged, 40.6% were admitted to general wards (GW), 5.9% to intensive care units (ICU), 2.4% to other hospitals, and 6.5% returned to LTCHs. ED length of stay (LOS) was longest in the death (410.28 ± 559.73 min) and GW admission (390.12 ± 621.71 min) groups. Falls were the main cause of injury (50.1%), and the most common fracture was femoral (71.6%). Femoral and shoulder/upper extremity fractures increased hospitalization risk only, whereas self-harm increased both hospitalization and mortality risk. CONCLUSION Visits to the ED by older patients from LTCH for trauma were avoidable in 50.6% of cases. Additionally, these patients had longer ED LOS and higher hospitalization rates than non-LTCH patients. Falls were the predominant mode of presentation, femoral fracture was the most common fracture among patients from LTCH.
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Affiliation(s)
- Yunhyung Choi
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Anyangcheonro 1071, YangChoengu, Seoul 07985, Korea; Chung-Ang University Gwangmyeong Hospital, Deokan-ro 110, Gwangmyeong-si, 14353 Gyeonggi-do, Republic of Korea
| | - Duk Hee Lee
- Department of Emergency Medicine, College of Medicine, Ewha Womans University, Anyangcheonro 1071, YangChoengu, Seoul 07985, Korea; Ewha Womans University Mokdong Hospital, Anyangcheonro 1071, Yangchoengu, Seoul 07985, Republic of Korea.
| | - Jongseok Oh
- Postdoctoral researcher, Graduate School of Public Administration, Seoul National University, Room 208, Bld 16, Gwanak-ro 1, Gwanak-gu, Seoul 08826, Republic of Korea.
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Leblanc J, Dusserre-Telmon L, Chauvin A, Simon T, Sabbatini CE, Hemming K, Colizza V, Bérard L, Convert J, Lazazga S, Jegou C, Taibi N, Dautheville S, Zaghia D, Gerlier C, Domergue M, Larrouturou F, Bonnet F, Fontanet A, Salhi S, LeGoff J, Crémieux AC. Intensified screening for SARS-CoV-2 in 18 emergency departments in the Paris metropolitan area, France (DEPIST-COVID): A cluster-randomized, two-period, crossover trial. PLoS Med 2023; 20:e1004317. [PMID: 38060611 PMCID: PMC10735176 DOI: 10.1371/journal.pmed.1004317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 12/21/2023] [Accepted: 11/02/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Asymptomatic and paucisymptomatic infections account for a substantial portion of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) transmissions. The value of intensified screening strategies, especially in emergency departments (EDs), in reaching asymptomatic and paucisymptomatic patients and helping to improve detection and reduce transmission has not been documented. The objective of this study was to evaluate in EDs whether an intensified SARS-CoV-2 screening strategy combining nurse-driven screening for asymptomatic/paucisymptomatic patients with routine practice (intervention) could contribute to higher detection of SARS-CoV-2 infections compared to routine practice alone, including screening for symptomatic or hospitalized patients (control). METHODS AND FINDINGS We conducted a cluster-randomized, two-period, crossover trial from February 2021 to May 2021 in 18 EDs in the Paris metropolitan area, France. All adults visiting the EDs were eligible. At the start of the first period, 18 EDs were randomized to the intervention or control strategy by balanced block randomization with stratification, with the alternative condition being applied in the second period. During the control period, routine screening for SARS-CoV-2 included screening for symptomatic or hospitalized patients. During the intervention period, in addition to routine screening practice, a questionnaire about risk exposure and symptoms and a SARS-CoV-2 screening test were offered by nurses to all remaining asymptomatic/paucisymptomatic patients. The primary outcome was the proportion of newly diagnosed SARS-CoV-2-positive patients among all adults visiting the 18 EDs. Primary analysis was by intention-to-treat. The primary outcome was analyzed using a generalized linear mixed model (Poisson distribution) with the center and center by period as random effects and the strategy (intervention versus control) and period (modeled as a weekly categorical variable) as fixed effects with additional adjustment for community incidence. During the intervention and control periods, 69,248 patients and 69,104 patients, respectively, were included for a total of 138,352 patients. Patients had a median age of 45.0 years [31.0, 63.0], and women represented 45.7% of the patients. During the intervention period, 6,332 asymptomatic/paucisymptomatic patients completed the questionnaire; 4,283 were screened for SARS-CoV-2 by nurses, leading to 224 new SARS-CoV-2 diagnoses. A total of 1,859 patients versus 2,084 patients were newly diagnosed during the intervention and control periods, respectively (adjusted analysis: 26.7/1,000 versus 26.2/1,000, adjusted relative risk: 1.02 (95% confidence interval (CI) [0.94, 1.11]; p = 0.634)). The main limitation of this study is that it was conducted in a rapidly evolving epidemiological context. CONCLUSIONS The results of this study showed that intensified screening for SARS-CoV-2 in EDs was unlikely to identify a higher proportion of newly diagnosed patients. TRIAL REGISTRATION Trial registration number: ClinicalTrials.gov NCT04756609.
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Affiliation(s)
- Judith Leblanc
- Sorbonne Université, INSERM, Pierre Louis Institute of Epidemiology and Public Health; Assistance Publique-Hôpitaux de Paris (AP-HP), Hôpital St Antoine, Clinical Research Platform Paris-East, Paris, France
| | | | - Anthony Chauvin
- AP-HP, Hôpital Lariboisière, Emergency department; Université Paris Cité, INSERM U942 MASCOT, Paris, France
| | - Tabassome Simon
- AP-HP, Hôpital St Antoine, Clinical Research Platform Paris-East; Sorbonne Université, Department of Clinical Pharmacology, Paris, France
| | - Chiara E. Sabbatini
- Sorbonne Université, INSERM, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| | - Karla Hemming
- University of Birmingham, Institute of Applied Health Research, Birmingham, United Kingdom
| | - Vittoria Colizza
- Sorbonne Université, INSERM, Pierre Louis Institute of Epidemiology and Public Health, Paris, France
| | - Laurence Bérard
- AP-HP, Hôpital St Antoine, Clinical Research Platform Paris-East, Paris, France
| | - Jérome Convert
- AP-HP, Hôpital Lariboisière, Emergency department, Paris, France
| | - Sonia Lazazga
- Centre Hospitalier de Gonesse, Emergency department, Gonesse, France
| | - Carole Jegou
- AP-HP, Hôpital Avicenne, Emergency department, Bobigny, France
| | - Nabila Taibi
- AP-HP, Hôpital Pitié-Salpêtrière, Emergency department, Paris, France
| | | | - Damien Zaghia
- AP-HP, Hôpital Beaujon, Emergency department, Clichy, France
| | - Camille Gerlier
- Hôpital Paris St Joseph, Emergency department, Paris, France
| | - Muriel Domergue
- AP-HP, Hôpital Européen Georges Pompidou, Emergency department, Paris, France
| | | | - Florence Bonnet
- AP-HP, Hôpital St Antoine, Emergency department, Paris, France
| | - Arnaud Fontanet
- Institut Pasteur, Emerging Diseases Epidemiology Unit; PACRI unit, Conservatoire National des Arts et Métiers, Paris, France
| | - Sarah Salhi
- AP-HP, Hôpital St Antoine, Clinical Research Platform Paris-East, Paris, France
| | - Jérome LeGoff
- Université Paris Cité, INSERM U976, INSIGHT Team; AP-HP, Hôpital St Louis, Virology Department, Paris, France
| | - Anne-Claude Crémieux
- AP-HP, Hôpital St Louis, Infectious Diseases Department; Université Paris Cité, FHU PROTHEE, Paris, France
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Zahid M, Khan AA, Ata F, Yousaf Z, Naushad VA, Purayil NK, Chandra P, Singh R, Kartha AB, Elzouki AYA, Al Mohanadi DHSH, Al-Mohammed AAAA. Medical Admission Prediction Score (MAPS); a simple tool to predict medical admissions in the emergency department. PLoS One 2023; 18:e0293140. [PMID: 37948401 PMCID: PMC10637671 DOI: 10.1371/journal.pone.0293140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 10/05/2023] [Indexed: 11/12/2023] Open
Abstract
INTRODUCTION Overcrowding in the emergency departments (ED) is linked to adverse clinical outcomes, a negative impact on patient safety, patient satisfaction, and physician efficiency. We aimed to design a medical admission prediction scoring system based on readily available clinical data during ED presentation. METHODS In this retrospective cross-sectional study, data on ED presentations and medical admissions were extracted from the Emergency and Internal Medicine departments of a tertiary care facility in Qatar. Primary outcome was medical admission. RESULTS Of 320299 ED presentations, 218772 were males (68.3%). A total of 11847 (3.7%) medical admissions occurred. Most patients were Asians (53.7%), followed by Arabs (38.7%). Patients who got admitted were older than those who did not (p <0.001). Admitted patients were predominantly males (56.8%), had a higher number of comorbid conditions and a higher frequency of recent discharge (within the last 30 days) (p <0.001). Age > 60 years, female gender, discharge within the last 30 days, and worse vital signs at presentations were independently associated with higher odds of admission (p<0.001). These factors generated the scoring system with a cut-off of >17, area under the curve (AUC) 0.831 (95% CI 0.827-0.836), and a predictive accuracy of 83.3% (95% CI 83.2-83.4). The model had a sensitivity of 69.1% (95% CI 68.2-69.9), specificity was 83.9% (95% CI 83.7-84.0), positive predictive value (PPV) 14.2% (95% CI 13.8-14.4), negative predictive value (NPV) 98.6% (95% CI 98.5-98.7) and positive likelihood ratio (LR+) 4.28% (95% CI 4.27-4.28). CONCLUSION Medical admission prediction scoring system can be reliably applied to the regional population to predict medical admissions and may have better generalizability to other parts of the world owing to the diverse patient population in Qatar.
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Affiliation(s)
- Muhammad Zahid
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Adeel Ahmad Khan
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Fateen Ata
- Department of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Zohaib Yousaf
- Department of Medicine, Reading Hospital-Tower Health, West Reading, PA, United States of America
| | | | - Nishan K. Purayil
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Prem Chandra
- Department of Medical Research, Medical Research Center, Academic Health System, Hamad Medical Corporation, Doha, Qatar
| | - Rajvir Singh
- Department of Medical Research, Medical Research Center, Academic Health System, Hamad Medical Corporation, Doha, Qatar
| | - Anand Bhaskaran Kartha
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Abdelnaser Y. Awad Elzouki
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Dabia Hamad S. H. Al Mohanadi
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Ahmed Ali A. A. Al-Mohammed
- Department of Medicine, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
- College of Medicine, Qatar University, Qatar, Qatar
- Weill Cornell Medicine, Ar-Rayyan, Qatar
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10
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Xiao Y, Zhang J, Chi C, Ma Y, Song A. Criticality and clinical department prediction of ED patients using machine learning based on heterogeneous medical data. Comput Biol Med 2023; 165:107390. [PMID: 37659113 DOI: 10.1016/j.compbiomed.2023.107390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/27/2023] [Accepted: 08/25/2023] [Indexed: 09/04/2023]
Abstract
PROBLEM Emergency triage faces multiple challenges, including limited medical resources and inadequate manual triage nurses, which cause incorrect triage, overcrowding in the emergency department (ED), and long patient waiting time. OBJECTIVE This paper aims to propose and validate an accurate and efficient artificial intelligence-based method for effectively ED triage and alleviating the pressure on medical resources. METHODS We propose two novel machine learning models, TransNet and TextRNN, for predicting patient severity levels and clinical departments using heterogeneous medical data in ED triage. Our models employ a parallel structure for feature extraction and incorporate an attention mechanism to extract essential information from the fused features, enabling accurate predictions. The models analyze the triage data (2020-2022) from the ED of Beijing University People's Hospital, incorporating variables (demographics, triage vital signs, and chief complaints) to identify patient severity levels and clinical departments. We performed data cleaning, categorization, and encoding first. Then, we divided the available data into a training set (56%), a validation set (24%), and a test set (20%) by random sampling. Finally, our models underwent 5-fold cross-validation and were compared with other state-of-the-art models. RESULTS We comprehensively evaluated the proposed models against various Recurrent Neural Networks (RNN), Convolutional Neural Networks (CNN), Traditional Machine Learning (TML), and Transformer-based (TF) models, achieving excellent performance in predicting triage outcomes. Specifically, TextRNN achieved a prediction success rate of 86.23% [85.86-86.70] for severity levels and 94.30% [94.00-94.46] for clinical departments among 161,198 ED visits. Moreover, TransNet demonstrated higher sensitivities of 84.08% and 90.05% for severity levels and clinical departments, respectively, with specificities of 76.48% and 95.16%. The accuracy of our model is 0.87%, 0.18%, 4.29%, and 1.96%, higher than that of the above four family models on average. Furthermore, our method significantly reduced under-triage by 12.06% and over-triage by 17.92% compared to manual triage. CONCLUSIONS Experimental results demonstrated that the proposed models fuse heterogeneous medical data in the triage process, successfully predicting patients' triage outcomes. Our models can improve triage efficiency, reduce the under/over-triage rate, and provide physicians with valuable decision-making support.
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Affiliation(s)
- Yi Xiao
- The State Key Laboratory of Digital Medical Engineering, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Jun Zhang
- The State Key Laboratory of Digital Medical Engineering, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China.
| | - Cheng Chi
- Department of Emergency, Peking University People's Hospital, Beijing, 100044, China
| | - Yuqing Ma
- The State Key Laboratory of Digital Medical Engineering, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
| | - Aiguo Song
- The State Key Laboratory of Digital Medical Engineering, School of Instrument Science and Engineering, Southeast University, Nanjing, 210096, China
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11
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Osmanlliu E, Burstein B, Tamblyn R, Buckeridge DL. Assessing the potential for virtualizable care in the pediatric emergency department. J Telemed Telecare 2022:1357633X221133415. [PMID: 36408736 DOI: 10.1177/1357633x221133415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
INTRODUCTION There is increasing interest for patient-to-provider telemedicine in pediatric acute care. The suitability of telemedicine (virtualizability) for visits in this setting has not been formally assessed. We estimated the proportion of in-person pediatric emergency department (PED) visits that were potentially virtualizable, and identified factors associated with virtualizable care. METHODS This was a retrospective analysis of in-person visits at the PED of a Canadian tertiary pediatric hospital (02/2018-12/2019). Three definitions of virtualizable care were developed: (1) a definition based on "resource use" classifying visits as virtualizable if they resulted in a home discharge, no diagnostic testing, and no return visit within 72 h; (2) a "diagnostic definition" based on primary ED diagnosis; and (3) a stringent "combined definition" by which visits were classified as virtualizable if they met both the resource use and diagnostic definitions. Multivariable logistic regression was used to identify factors associated with telemedicine suitability. RESULTS There were 130,535 eligible visits from 80,727 individual patients during the study period. Using the most stringent combined definition of telemedicine suitability, 37.9% (95% confidence interval (CI) 37.6%-38.2%) of in-person visits were virtualizable. Overnight visits (adjusted odds ratio (aOR) 1.16-1.37), non-Canadian citizenship (aOR 1.10-1.18), ethnocultural vulnerability (aOR 1.14-1.22), and a consultation for head trauma (aOR 3.50-4.60) were associated with higher telemedicine suitability across definitions. DISCUSSION There is a high potential for patient-to-provider telemedicine in the PED setting. Local patient and visit-level characteristics must be considered in the design of safe and inclusive telemedicine models for pediatric acute care.
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Affiliation(s)
- Esli Osmanlliu
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- Pediatric Emergency Medicine Division, 12367McGill University Health Center, McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
| | - Brett Burstein
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- Pediatric Emergency Medicine Division, 12367McGill University Health Center, McGill University, Montréal, Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
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12
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Lin P, Argon NT, Cheng Q, Evans CS, Linthicum B, Liu Y, Mehrotra A, Patel MD, Ziya S. Disparities in emergency department prioritization and rooming of patients with similar triage acuity score. Acad Emerg Med 2022; 29:1320-1328. [PMID: 36104028 DOI: 10.1111/acem.14598] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 09/02/2022] [Accepted: 09/12/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND We identify patient demographic and emergency department (ED) characteristics associated with rooming prioritization decisions among ED patients who are assigned the same triage acuity score. METHODS We performed a retrospective analysis of adult ED patients with similar triage acuity, as defined as an Emergency Severity Index (ESI) of 3, at a large academic medical center, during 2019. Violations of a first-come-first-served (FCFS) policy for rooming are identified and used to create weighted multiple logistic regression models and 1:M matched case-control conditional logistic regression models to determine how rooming prioritization is affected by individual patient age, sex, race, and ethnicity after adjusting for patient clinical and time-varying ED operational characteristics. RESULTS A total of 15,781 ED encounters were analyzed, with 1612 (10.2%) ED encounters having a rooming prioritization in violation of a FCFS policy. Patient age and race were found to be significantly associated with being prioritized in violation of FCFS in both logistic regression models. The 1:M matched model showed a statistically significant relationship between violation of rooming prioritization with increasing age in years (adjusted odds ratio [aOR] 1.009, 95% confidence interval [CI] 1.005-1.013) and among African American patients compared to Caucasians (aOR 0.636, 95% CI 0.545-0.743). CONCLUSIONS Among ED patients with a similar triage acuity (ESI 3), we identified patient age and patient race as characteristics that were associated with deviation from a FCFS prioritization in ED rooming decisions. These findings suggest that there may be patient demographic disparities in ED rooming decisions after adjusting for clinical and ED operational characteristics.
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Affiliation(s)
- Peter Lin
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Nilay T Argon
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Qian Cheng
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Christopher S Evans
- Information Services, ECU Health, Greenville, North Carolina, USA.,Department of Emergency Medicine, East Carolina University, Greenville, North Carolina, USA
| | - Benjamin Linthicum
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Yufeng Liu
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Genetics, University of North Carolina, Chapel Hill, North Carolina, USA.,Department of Biostatistics, University of North Carolina, Chapel Hill, North Carolina, USA.,Carolina Center for Genome Sciences, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Abhishek Mehrotra
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Serhan Ziya
- Department of Statistics and Operations Research, University of North Carolina, Chapel Hill, North Carolina, USA
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13
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Hanscom D, Dutton DJ. Effect of the COVID-19 pandemic on the socioeconomic composition of emergency department presentations. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2022; 113:878-886. [PMID: 35969354 PMCID: PMC9377289 DOI: 10.17269/s41997-022-00684-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Accepted: 07/27/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES This study highlights how socioeconomic trends in the emergency department (ED) for low-acuity visits change with the onset of COVID-19, identifies societal inequities exacerbated by the pandemic, and demonstrates the geographical regions where these inequities occur. METHODS We accessed 1,285,000 ED visits from 12 different facilities across New Brunswick from January 2017 to October 2020. Using a deprivation index developed by Statistics Canada as a measure of socioeconomic status, and controlling for additional factors, we perform a logistic regression to determine the influence of the COVID-19 pandemic on low-acuity visits of individuals from the most deprived quintile (Q5). We constructed a heat map of New Brunswick to highlight regions of high deprivation. RESULTS The proportion of Q5 individuals in the ethnocultural composition domain accessing the ED for low-acuity visits increased from 22.91% to 24.72% with the onset of the pandemic. Our logistic regression showed the log odds of being considered Q5 in the ethnocultural composition domain when visiting the ED for a low-acuity reason increased by 6.3% if the visit occurred during the pandemic, and increased by 101.6% if the visit occurred in one of the 3 major regions of New Brunswick. CONCLUSION Individuals visiting EDs for low-acuity reasons during the COVID-19 pandemic were more likely to be from the most diverse quintile in the ethnocultural domain, and the inequities were concentrated in the most urban regions in New Brunswick. This demonstrates that urban areas are where inequities are disproportionately faced for ethnically diverse individuals and demonstrates where policies could be focused.
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Affiliation(s)
- Daniel Hanscom
- Faculty of Medicine, Dalhousie University, 100 Tucker Park Road, Saint John, NB E2K 5E2 Canada
| | - Daniel J. Dutton
- Department of Community Health & Epidemiology, Dalhousie University, Saint John, NB Canada
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14
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Atwood CE, Bhutani M, Ospina MB, Rowe BH, Leigh R, Deuchar L, Faris P, Michas M, Mrklas KJ, Graham J, Aceron R, Damant R, Green L, Hirani N, Longard K, Meyer V, Mitchell P, Tsai W, Walker B, Stickland MK. Optimizing COPD Acute Care Patient Outcomes Using a Standardized Transition Bundle and Care Coordinator. Chest 2022; 162:321-330. [DOI: 10.1016/j.chest.2022.03.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 03/09/2022] [Accepted: 03/22/2022] [Indexed: 10/18/2022] Open
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15
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Bhaumik S, Hannun M, Dymond C, DeSanto K, Barrett W, Wallis LA, Mould-Millman NK. Prehospital triage tools across the world: a scoping review of the published literature. Scand J Trauma Resusc Emerg Med 2022; 30:32. [PMID: 35477474 PMCID: PMC9044621 DOI: 10.1186/s13049-022-01019-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/19/2022] [Indexed: 01/15/2023] Open
Abstract
Background Accurate triage of the undifferentiated patient is a critical task in prehospital emergency care. However, there is a paucity of literature synthesizing currently available prehospital triage tools. This scoping review aims to identify published tools used for prehospital triage globally and describe their performance characteristics. Methods A comprehensive search was performed of primary literature in English-language journals from 2009 to 2019. Papers included focused on emergency medical services (EMS) triage of single patients. Two blinded reviewers and a third adjudicator performed independent title and abstract screening and subsequent full-text reviews. Results Of 1521 unique articles, 55 (3.6%) were included in the final synthesis. The majority of prehospital triage tools focused on stroke (n = 19; 35%), trauma (19; 35%), and general undifferentiated patients (15; 27%). All studies were performed in high income countries, with the majority in North America (23, 42%) and Europe (22, 40%). 4 (7%) articles focused on the pediatric population. General triage tools aggregate prehospital vital signs, mental status assessments, history, exam, and anticipated resource need, to categorize patients by level of acuity. Studies assessed the tools’ ability to accurately predict emergency department triage assignment, hospitalization and short-term mortality. Stroke triage tools promote rapid identification of patients with acute large vessel occlusion ischemic stroke to trigger timely transport to diagnostically- and therapeutically-capable hospitals. Studies evaluated tools’ diagnostic performance, impact on tissue plasminogen activator administration rates, and correlation with in-hospital stroke scales. Trauma triage tools identify patients that require immediate transport to trauma centers with emergency surgery capability. Studies evaluated tools’ prediction of trauma center need, under-triage and over-triage rates for major trauma, and survival to discharge. Conclusions The published literature on prehospital triage tools predominantly derive from high-income health systems and mostly focus on adult stroke and trauma populations. Most studies sought to further simplify existing triage tools without sacrificing triage accuracy, or assessed the predictive capability of the triage tool. There was no clear ‘gold-standard’ singular prehospital triage tool for acute undifferentiated patients. Trial registration Not applicable.
Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01019-z.
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Affiliation(s)
- Smitha Bhaumik
- Department of Emergency Medicine, Denver Health and Hospital Authority, 777 Bannock St, Denver, CO, 80204, USA.,Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA
| | - Merhej Hannun
- Department of Family Medicine, Reading Hospital - Tower Health, 420 South 5th Avenue, West Reading, PA, 19611, USA
| | - Chelsea Dymond
- Department of Emergency Medicine, Providence St Joseph Hospital, 2700 Dolbeer St, Eureka, CA, 95501, USA
| | - Kristen DeSanto
- Strauss Health Sciences Library, School of Medicine, University of Colorado Anschutz Medical Campus, 12950 E. Montview Blvd., Mail Stop A003, Aurora, CO, 80045, USA
| | - Whitney Barrett
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, 1 University of New Mexico, MSC11 6025, Albuquerque, NM, 87131, USA
| | - Lee A Wallis
- Division of Emergency Medicine, Groote Schuur Hospital, University of Cape Town, F51 Old Main Building, Observatory, Cape Town, 7935, South Africa
| | - Nee-Kofi Mould-Millman
- Department of Emergency Medicine, School of Medicine, University of Colorado, 12631 E. 17th Ave, Room 2612, MS C326, Aurora, CO, 80045, USA. .,Division of Emergency Medicine, Groote Schuur Hospital, University of Cape Town, F51 Old Main Building, Observatory, Cape Town, 7935, South Africa.
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16
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Bechard M, Cloutier P, Lima I, Salamatmanesh M, Zemek R, Bhatt M, Suntharalingam S, Kurdyak P, Baker M, Gardner W. Cannabis-related emergency department visits by youths and their outcomes in Ontario: a trend analysis. CMAJ Open 2022; 10:E100-E108. [PMID: 35135825 PMCID: PMC9259464 DOI: 10.9778/cmajo.20210142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cannabis-related emergency department visits can be an entry point for youths to mental health and substance use care systems. We aimed to examine trends in cannabis-related emergency department visits as a function of youths' age and sex. METHODS Using administrative data, we examined all visits to emergency departments in Ontario, Canada, from 2003 to 2017, by youth aged 10-24 years (grouped as 10-13, 14-18 and 19-24 yr) to determine trends in cannabis-related emergency department visits. Cannabis-related visits were identified using International Statistical Classification of Diseases and Related Health Problems, 10th Revision codes for cannabis poisoning and mental disorders due to cannabinoids. We categorized presentations as "less severe" versus "more severe" using scores assigned by nurses at triage. RESULTS We examined 14 697 778 emergency department visits. Cannabis-related visits increased from 3.8 per 10 000 youths (95% confidence interval [CI] 3.5-4.0) in 2003 to 17.9 (95% CI 17.4-18.4) in 2017, a 4.8-fold increase (95% CI 4.4-5.1). Rates increased for both sexes and each age group. Males were more likely to have a visit than females (rate ratios ≥ 1.5 in 2003 and 2017). The number of cannabis-related visits in 2017 was 25.0 per 10 000 (95% CI 24.0-25.9) among youth aged 19-24 years, 21.9 per 10 000 (95% CI 20.9-22.9) among those aged 14-18 years, and 0.8 per 10 000 (95% CI 0.5-1.0) among those aged 10-13 years. In 2017, 88.2% (95% CI 87.3%-89.0%) of cannabis-related visits and 58.1% (95% CI 58.0%-58.2%) of non-cannabis-related visits were triaged as "more severe," (rate ratio 1.52, 95% CI 1.50-1.53). Similarly, in 2017, 19.0% (95% CI 18.0%-20.1%) of cannabis-related visits and 5.8% (95% CI 5.7%-5.8%) of non-cannabis-related visits resulted in hospital admission (rate ratio 3.3, 95% CI 3.1-3.5). INTERPRETATION Rates of cannabis-related emergency department visit by youths aged 10-24 years increased almost fivefold from 2003 to 2017, with increases in visit severity and hospital admissions. These trends describe an emerging public health problem, and research is needed to identify the causes of this increase and the health and social consequences of cannabis-related visits for these youths.
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Affiliation(s)
- Melanie Bechard
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - Paula Cloutier
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - Isac Lima
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - Mina Salamatmanesh
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - Roger Zemek
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - Maala Bhatt
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - Sinthuja Suntharalingam
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - Paul Kurdyak
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - Melissa Baker
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont
| | - William Gardner
- Department of Pediatrics (Bechard, Zemek, Bhatt), University of Ottawa; Children's Hospital of Eastern Ontario Research Institute (Cloutier, Salamatmanesh, Zemek, Bhatt, Gardner); ICES uOttawa (Lima); Department of Psychiatry (Suntharalingam, Gardner), University of Ottawa, Ottawa, Ont.; The Centre for Addiction and Mental Health (Kurdyak); Department of Psychiatry (Kurdyak), University of Toronto, Toronto, Ont.; Public Health Agency of Canada (Baker); School of Epidemiology and Public Health (Gardner), University of Ottawa, Ottawa, Ont.
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17
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Alshaibi S, AlBassri T, AlQeuflie S, Philip W, Alharthy N. Pediatric triage variations among nurses, pediatric and emergency residents using the Canadian triage and acuity scale. BMC Emerg Med 2021; 21:146. [PMID: 34809562 PMCID: PMC8607564 DOI: 10.1186/s12873-021-00541-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 11/10/2021] [Indexed: 11/10/2022] Open
Abstract
Background Emergency care continues to be a challenge, since patients’ arrival is unscheduled and could occur at the same time which may fill the Emergency Department with non-urgent patients. Triaging is an integral part of every busy ED. The Canadian Triage and Acuity Scale (CTAS) is considered an accurate tool to be used outside Canada. This study aims to identify the chosen triage level and compare the variation between registered nurses, pediatric and adult emergency residents by using CTAS cases. Method This study was conducted at King Abdulaziz Medical City,Saudi Arabia. A cross-sectional self-administered questionnaire was used, and which contains 15 case scenarios with different triage levels. All cases were adopted from a Canadian triage course after receiving permission. Each case provides the patient’s symptoms, clinical signs and mode of arrival to the ED. The participants were instructed to assign a triage level using the following scale. A non-random sampling technique was used for this study. The rates of agreement between residents were calculated using kappa statistics (weighted-kappa) (95%CI). Result A total of 151 participants completed the study questionnaire which include 15 case scenarios. 73 were nurses and 78 were residents. The results showed 51.3, 56.6, and 59.9% mis-triaged the cases among the nurses, emergency residents, and pediatric residents respectively. Triage scores were compared using the Kruskal Wallis test and were statistically significant with a p value of 0.006. The mean ranks for nurses, emergency residents and pediatric residents were 86.41, 73.6 and 59.96, respectively. The Kruskal Wallis Post-Hoc test was performed to see which groups were statistically significant, and it was found that there was a significant difference between nurses and pediatrics residents (P value = 0.005). Moreover, there were no significant differences found between nurses and ER residents (P value> 0.05). Conclusion The triaging system was found to be a very important tool to prioritize patients based on their complaints. The results showed that nurses had the greatest experience in implementing patients on the right triage level. On the other hand, ER and pediatric residents need to develop more knowledge about CTAS and become exposed more to the triaging system during their training.
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Affiliation(s)
- Saleh Alshaibi
- Collage of Medicine, King Saud bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia.
| | - Tala AlBassri
- Collage of Medicine, King Saud bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia
| | - Suliman AlQeuflie
- Department of Pediatrics, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Winnie Philip
- Research Unit, College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Science, Riyadh, Saudi Arabia
| | - Nesrin Alharthy
- Department of Pediatrics Emergency, Emergency Department- King Abdulaziz Medical City, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
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18
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Osmanlliu E, Gagnon I, Weber S, Bach CQ, Turnbull J, Seguin J. The Waiting Room Assessment to Virtual Emergency Department pathway: Initiating video-based telemedicine in the pediatric emergency department. J Telemed Telecare 2021; 28:452-457. [PMID: 34636683 DOI: 10.1177/1357633x211044038] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The COVID-19 pandemic has presented pediatric emergency departments with unique challenges, resulting in a heightened demand for adapted clinical pathways. In response to this need, the Montreal Children's Hospital pediatric emergency department introduced the WAVE (Waiting Room Assessment to Virtual Emergency Department) pathway, a video-based telemedicine pathway for selected non-critical patients, aiming to reduce safety issues related to emergency department overcrowding, while providing timely care to all children presenting and registering at our emergency department. The objective of the WAVE pilot phase was to evaluate the feasibility and acceptability of telemedicine in our pediatric emergency department, which was previously unfamiliar with this mode of care delivery. During the six-week, three-evening per week deployment, we conducted 18 five-hour telemedicine shifts. In total, 27 patients participated in the WAVE pathway. Results from this pilot phase met four of five a priori feasibility and acceptability criteria. Overall, participating families were satisfied with this novel care pathway and reported no disruptive technological barriers.
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Affiliation(s)
- Esli Osmanlliu
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada.,507266Research Institute of the McGill University Health Centre (RI-MUHC)
| | - Isabelle Gagnon
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada.,507266Research Institute of the McGill University Health Centre (RI-MUHC)
| | - Saskia Weber
- Quality and Continuous Improvement Office, 10040Montreal Children's Hospital, Canada
| | - Chi Quan Bach
- Partnership Office, 54473McGill University Health Centre, Canada
| | - Jennifer Turnbull
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada
| | - Jade Seguin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Montreal Children's Hospital, McGill University, Canada.,507266Research Institute of the McGill University Health Centre (RI-MUHC)
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19
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Chiu M, Gatov E, Fung K, Kurdyak P, Guttmann A. Deconstructing The Rise In Mental Health-Related ED Visits Among Children And Youth In Ontario, Canada. Health Aff (Millwood) 2021; 39:1728-1736. [PMID: 33017254 DOI: 10.1377/hlthaff.2020.00232] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Mental illness is a leading cause of disability among youth. In Ontario, Canada, rates of mental health or addiction-related emergency department (ED) visits continue to rise in children and youth; however, it is unclear what is driving this change. We deconstructed this trend by sociodemographic and clinical characteristics, using linked health administrative data sets. Mental health or addiction-related ED visit rates increased by 89.1 percent between 2006 and 2017, with the greatest rise observed for those ages 14-21, high-acuity cases, and anxiety and mood disorders. We observed a significantly sharp increase after 2009, when several socioenvironmental changes occurred, including the emergence of social media and the Great Recession. Our findings of greater numbers of teenagers and young adults experiencing mental health problems and a shift in acuity and diagnoses have important implications for both ED staffing and outpatient mental illness prevention efforts. Further research is needed to examine whether better case management, care coordination, and after-hours services will help reverse these trends.
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Affiliation(s)
- Maria Chiu
- Maria Chiu is a scientist in the Mental Health and Addictions Research Program at ICES and an assistant professor in the Institute of Health Policy, Management, and Evaluation at the University of Toronto, both in Toronto, Ontario, Canada
| | - Evgenia Gatov
- Evgenia Gatov is a senior epidemiologist in the Mental Health and Addictions Research Program at ICES
| | | | - Paul Kurdyak
- Paul Kurdyak is a lead in the Mental Health and Addictions Research Program at ICES and the medical director of performance improvement at the Centre for Addiction and Mental Health, in Toronto, Ontario, Canada
| | - Astrid Guttmann
- Astrid Guttmann is a chief science officer at ICES and a senior scientist at the Hospital for Sick Children, in Toronto, Ontario, Canada
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20
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Calder LA, Perry J, Yan JW, De Gorter R, Sivilotti MLA, Eagles D, Myslik F, Borgundvaag B, Émond M, McRae AD, Taljaard M, Thiruganasambandamoorthy V, Cheng W, Forster AJ, Stiell IG. Adverse Events Among Emergency Department Patients With Cardiovascular Conditions: A Multicenter Study. Ann Emerg Med 2021; 77:561-574. [PMID: 33612283 DOI: 10.1016/j.annemergmed.2020.12.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We aim to determine incidence and type of adverse events (adverse outcomes related to emergency care) among emergency department (ED) patients discharged with recent-onset atrial fibrillation, acute heart failure, and syncope. METHODS This 5-year prospective cohort study included high-acuity adult patients discharged with the 3 sentinel diagnoses from 6 tertiary care Canadian EDs. We screened all ED visits for eligibility and performed telephone interviews 14 days postdischarge to identify flagged outcomes: death, hospital admission, return ED visit, health care provider visit, and new or worsening symptoms. We created case summaries describing index ED visit and flagged outcomes, and trained emergency physicians reviewed case summaries to identify adverse events. We reported adverse event incidence and rates with 95% confidence intervals and contributing factor themes. RESULTS Among 4,741 subjects (mean age 70.2 years; 51.2% men), we observed 170 adverse events (3.6 per 100 patients; 95% confidence interval 3.1 to 4.2). Patients discharged with acute heart failure were most likely to experience adverse events (5.3%), followed by those with atrial fibrillation (2.0%) and syncope (0.8%). We noted variation in absolute adverse event rates across sites from 0.7 to 6.0 per 100 patients. The most common adverse event types were management issues, diagnostic issues, and unsafe disposition decisions. Frequent contributing factor themes included failure to recognize underlying causes and inappropriate management of dual diagnoses. CONCLUSION Among adverse events after ED discharge for patients with these 3 sentinel cardiovascular diagnoses, we identified quality improvement opportunities such as strengthening dual diagnosis detection and evidence-based clinical practice guideline adherence.
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Affiliation(s)
- Lisa A Calder
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin W Yan
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Ria De Gorter
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marco L A Sivilotti
- Departments of Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, Canada
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Frank Myslik
- Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, Western University, Lawson Health Research Institute, London, Ontario, Canada
| | - Bjug Borgundvaag
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Marcel Émond
- Département de médecine Familiale et d'Urgence, Université Laval, Québec City, Quebec, Canada
| | - Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Monica Taljaard
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Venkatesh Thiruganasambandamoorthy
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Alan J Forster
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
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21
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Weerasinghe SS, Campbell SG. Identifying Acuity Level-Based Adult Emergency Department Use Time Trends Across Demographic Characteristics. Cureus 2021; 13:e13225. [PMID: 33728175 PMCID: PMC7946331 DOI: 10.7759/cureus.13225] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Introduction Canadian emergency departments (EDs) are struggling under the weight of increased use by a growing population of elderly patients; those who lack proper housing; and those who lack family physicians to provide primary care. The Canadian Foundation for Healthcare Improvement projected a possible ED service utilization increase in Canada at a rate of 40% over three decades. This calls for local-level information on the time trends to understand demographic and temporal variations in the different geographical locations in the country. This study sought to identify and quantify acuity level-based per capita ED visit annual time trends for the 10-year period of 2006-2015 (by age, gender, and housing status). The aim is to provide detailed information on the time trends for demographically targeted ED planning locally. The lengthy record of data allows examining the changing directions in different time segments. Material and methods Administrative data from the largest emergency department in Halifax (Nova Scotia, Canada) was analyzed. Per capita adult ED visit rates (EDVR) based on Canadian Triage Acuity Scale (CTAS), age, gender, and housing status were analyzed. Trends in the age-gender-based standardized rates using 2011 census city population data were also estimated in order to account for the population increase in the city. Results No study in Canada has documented the possibility of flattening the escalating ED visit trend by maintaining an annual declining trend in low-acuity-level visits or documented a threshold rate of decline to be maintained. This study observed that the annual linear per capita non-homeless EDVR increment trend (328/year, CI:245-411, per 100,000) for all-acuity-level visits - noted for a ten-year period - would become stable when low-acuity-level CTAS4-5 visit declining trends (427/year, CI:350-503 and 121/year, CI:79-163, per 100,000) - noted for the period of 2012-2015 - were maintained at the same magnitude and direction. Alarming annual emergent (high acuity level of CTAS2) EDVR increase equivalent to 335/year (CI:280-391, per 100,000) was noted for all combined visits, from all age, gender, and housing groups visits. The highest incremental rate noted among above-50-year-olds (521/year, per 100,000, 95% CI:433-608) was neither driven by overall increasing population census numbers nor by increasing aging population numbers. We found statistically similar age-gender standardized rates (294/year, CI: 207-382) for all ED visits and (316/year, CI:261-372) for CTAS2 level visits, when adjusted for annual population increase. Homeless ED visits did not contribute to the overall ED visit incremental trend. The highest annual homeless increment rate was shown for <30-year-old group high acuity CTAS-2 level visits (219/year, CI:193-246, per 100,000). Conclusion Neither the city population increase nor increased homeless visits contributed to ED visit annual per capita incremental trends in the city of Halifax. The increasing trend was chiefly driven by high-acuity-level visits by >50-year-old patients. Our findings suggest one way to make this escalating ED visit rates stable in the future is by maintaining the declining semi-urgent and non-urgent visit trends at the same rates estimated within the years 2012-2015. These findings highlight the potential directions for ED services planning to keep up with the growing demand for high-acuity-level ED services by the aging population.
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Affiliation(s)
- Swarna S Weerasinghe
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, CAN
| | - Sam G Campbell
- Department of Emergency Medicine, Dalhousie University, Halifax, CAN
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22
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Hong M, Thind A, Zaric GS, Sarma S. Emergency department use following incentives to provide after-hours primary care: a retrospective cohort study. CMAJ 2021; 193:E85-E93. [PMID: 33462144 PMCID: PMC7835087 DOI: 10.1503/cmaj.200277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2020] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND: Access to primary care outside of regular working hours is limited in many countries. This study investigates the relation between the after-hours premium, an incentive for primary care physicians to provide services after hours, and less-urgent visits to the emergency department in Ontario, Canada. METHODS: We analyzed a retrospective cohort of a random sample of Ontario residents from April 2002 to March 2006, and a subcohort of patients followed from April 2005 to March 2016. We linked patient and primary care physician data with emergency department visit data. We used fixed-effects regression models to analyze the association between the introduction of the after-hours premium, as well as subsequent increases in the value of the premium, and the number of monthly emergency department visits. RESULTS: The sample consisted of 586 534 patients between 2002 and 2006, and 201 594 patients from 2005 to 2016. After controlling for patient and physician characteristics, seasonality and time-invariant patient confounding factors, introduction of the after-hours premium was associated with a reduction of 1.26 less-urgent visits to the emergency department per 1000 patients per month (95% confidence interval −1.48 to −1.04). Most of this reduction was observed in after-hours visits. Sensitivity analysis showed that the monthly reduction in less-urgent visits to the emergency department was in the range of −1.24 to −1.16 per 1000 patients. Subsequent increases in the after-hours premium were associated with a small reduction in less-urgent visits to the emergency department. INTERPRETATION: Ontario’s experience suggests that incentivizing physicians to improve access to after-hours primary care reduces some less-urgent visits to the emergency department. Other jurisdictions may consider incentives to limit less-urgent visits to the emergency department.
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Affiliation(s)
- Michael Hong
- Department of Epidemiology and Biostatistics (Hong, Thind, Zaric, Sarma), and Interfaculty Program in Public Health (Thind), Schulich School of Medicine & Dentistry, Western University; Ivey Business School (Zaric), Western University, London, Ont
| | - Amardeep Thind
- Department of Epidemiology and Biostatistics (Hong, Thind, Zaric, Sarma), and Interfaculty Program in Public Health (Thind), Schulich School of Medicine & Dentistry, Western University; Ivey Business School (Zaric), Western University, London, Ont
| | - Gregory S Zaric
- Department of Epidemiology and Biostatistics (Hong, Thind, Zaric, Sarma), and Interfaculty Program in Public Health (Thind), Schulich School of Medicine & Dentistry, Western University; Ivey Business School (Zaric), Western University, London, Ont
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics (Hong, Thind, Zaric, Sarma), and Interfaculty Program in Public Health (Thind), Schulich School of Medicine & Dentistry, Western University; Ivey Business School (Zaric), Western University, London, Ont.
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23
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Chisholm D, Wang D, Rich TA, Grabove M, Sherlock K, Lang E. A Multimodal Evaluation of an Emergency Department Electronic Tracking Board Utility Designed to Optimize Stretcher Utilization. Cureus 2020; 12:e11810. [PMID: 33409055 PMCID: PMC7779174 DOI: 10.7759/cureus.11810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objectives The primary objective of this study was to evaluate the impact of an electronic tracking board feature encouraging staff to prompt optimal patient location on total stretcher time (TST) amongst patients moved to a chair in an internal emergency department (ED) waiting room. As a secondary objective, we also sought to identify facilitators and barriers to the tool’s use amongst the ED staff. Methods Using an administrative database, a retrospective cohort design was used to compare TST between visits where the tool was used and not used amongst patients relocated from initial assessment space to a chair over an 11.5 month period. A mixed-methods design was used to investigate facilitators and barriers to the tool’s use amongst the ED staff. Response proportions were used to report Likert scale questions; thematic analysis was used to code themes. Results A total of 56,852 patients met the inclusion criteria and were moved to a chair. The tool was used 4,301 times, with “OK for chairs” selected for 3,917/56,852 (6.9%) patients and “not OK for chairs” selected 384/56,852 (0.7%) times. Patient characteristics were similar between both groups. Median interquartile range (IQR) TST amongst patients moved to a chair via the prompt was shorter than when the prompt was not used (148.2 (112.6) mins vs 154.4 (115.4) mins, p = 0.005). A total of 125 questionnaires were completed; 95% of staff were aware of the tool and 70% agreed/strongly agreed the tool could improve ED flow. Commonly reported physician barriers to use were forgetting to use the tool; common nursing barriers were lack of chair space and increased workload. Conclusions Despite low function use, prompt use was associated with reduced TST amongst ED patients relocated to a chair.
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24
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Casalino E, Choquet C, Bouzid D, Peyrony O, Curac S, Revue E, Fontaine JP, Plaisance P, Chauvin A, Ghazali DA. Analysis of Emergency Department Visits and Hospital Activity during Influenza Season, COVID-19 Epidemic, and Lockdown Periods in View of Managing a Future Disaster Risk: A Multicenter Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E8302. [PMID: 33182696 PMCID: PMC7698314 DOI: 10.3390/ijerph17228302] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 12/14/2022]
Abstract
ED-visits and through-ED admissions to medical/surgical wards (MSW) and intensive care unit (ICU) during influenza, COVID-19 and lockdown periods were evaluated in a four-hospital prospective observational study from November 2018 to March 2020. ED visit characteristics and main diagnostic categories were assessed. Analysis of 368,262 ED-visits highlighted a significantly increasing trend in ED-visits during influenza followed by a significantly decreasing trend after lockdown. For MSW-admissions, a pattern of growth during influenza was followed by a fall that began during COVID-19 pandemic and intensified during the lockdown. For ICU-admissions, a significant rise during the COVID-19 pandemic was followed by diminution during the lockdown period. During lockdown, significantly diminishing trends were shown for all diagnostic categories (between -40.8% and -73.6%), except influenza-like illness/COVID cases (+31.6%), Pulmonary embolism/deep vein thrombosis (+33.5%) and frequent users (+188.0%). The present study confirms an increase in demand during the influenza epidemic and during the initial phase of the COVID-19 epidemic, but a drop in activity during the lockdown, mainly related to non-COVID conditions. Syndromic surveillance of ILI cases in ED is a tool for monitoring influenza and COVID-19, and it can predict ED activity and the need for MSW and ICU beds.
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Affiliation(s)
- Enrique Casalino
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France; (E.C.); (C.C.); (D.B.)
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- IAME (Infection, Antimicrobial, Modeling, Evaluation), INSERM UMR1137, Université de Paris, 75018 Paris, France
| | - Christophe Choquet
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France; (E.C.); (C.C.); (D.B.)
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
| | - Donia Bouzid
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France; (E.C.); (C.C.); (D.B.)
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- IAME (Infection, Antimicrobial, Modeling, Evaluation), INSERM UMR1137, Université de Paris, 75018 Paris, France
| | - Olivier Peyrony
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Louis, 75010 Paris, France
| | - Sonja Curac
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, 92110 Clichy, France
| | - Eric Revue
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, 75010 Paris, France
| | - Jean-Paul Fontaine
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Saint Louis, 75010 Paris, France
| | - Patrick Plaisance
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, 75010 Paris, France
| | - Anthony Chauvin
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Lariboisière, 75010 Paris, France
- Centre of Research in Epidemiology and Statistics, INSERM UMR1153, Université Sorbonne, 75004 Paris, France
| | - Daniel Aiham Ghazali
- Emergency Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France; (E.C.); (C.C.); (D.B.)
- Study Group for Efficiency and Quality of Emergency Departments and Non-Scheduled Activities Departments, Assistance Publique-Hôpitaux de Paris, 75018 Paris, France; (O.P.); (S.C.); (E.R.); (J.-P.F.); (P.P.); (A.C.)
- IAME (Infection, Antimicrobial, Modeling, Evaluation), INSERM UMR1137, Université de Paris, 75018 Paris, France
- Emergency Medical Services, Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, 92110 Clichy, France
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25
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Cai X, Wu J, Chen J, Sun J, Li P. The "two-step four-level + " pediatric triage method in a medical center in Southern China. J SPEC PEDIATR NURS 2020; 25:e12305. [PMID: 32702207 DOI: 10.1111/jspn.12305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 06/04/2020] [Accepted: 07/09/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE Because the quality of medical resources is extremely uneven across China, it is nearly impossible to implement a unified emergency triage program. The aim of the study is to examine triage using the "two-step four-level+ " triage model in a hospital in Southern China, with an emphasis on hand, foot, and mouth disease. DESIGN AND METHODS This was a retrospective study of all patients seen in the pediatric emergency room (ER) between January 1, 2012 and December 31, 2018, at the Guangzhou Women and Children's Medical Center. The "two-step and four-level+ " was manually implemented in 2012, and an electronic triage system was developed and applied since 2015. Emergency quality control indicators were analyzed. RESULTS There were 645,473 patients triaged at the pediatric ER between January 1, 2015 and December 31, 2018. After the first step, 17,444 patients were classified as unstable, including 6546 (1.01%) Level I patients, 10,898 (1.69%) Level II patients, 210,368 (32.5%) Level III patients, and 417,661 (64.8%) Level IV patients. After triage implementation, the stay time of the patient in the pediatric ER decreased each year (all p < .05) and shortened to 20.3 ± 2.2 h in 2018. Compared with 2012-2014, the mortality of 2015-2018 decreased by 21.1%, the rate of unexpected resuscitation was 0%, and the complaints of overcrowding decreased (all p < .05). PRACTICE IMPLICATIONS This "two-step four-level+ " triage method can improve the medical care quality of pediatric ER in China.
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Affiliation(s)
- Xian Cai
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jinxia Wu
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jiechan Chen
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Jing Sun
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
| | - Peiqing Li
- Department of Pediatric Emergency, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, Guangdong, China
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Improving Emergency Department Efficiency by Patient Scheduling Using Deep Reinforcement Learning. Healthcare (Basel) 2020; 8:healthcare8020077. [PMID: 32230962 PMCID: PMC7349722 DOI: 10.3390/healthcare8020077] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 12/02/2022] Open
Abstract
Emergency departments (ED) in hospitals usually suffer from crowdedness and long waiting times for treatment. The complexity of the patient’s path flows and their controls come from the patient’s diverse acute level, personalized treatment process, and interconnected medical staff and resources. One of the factors, which has been controlled, is the dynamic situation change such as the patient’s composition and resources’ availability. The patient’s scheduling is thus complicated in consideration of various factors to achieve ED efficiency. To address this issue, a deep reinforcement learning (RL) is designed and applied in an ED patients’ scheduling process. Before applying the deep RL, the mathematical model and the Markov decision process (MDP) for the ED is presented and formulated. Then, the algorithm of the RL based on deep Q-networks (DQN) is designed to determine the optimal policy for scheduling patients. To evaluate the performance of the deep RL, it is compared with the dispatching rules presented in the study. The deep RL is shown to outperform the dispatching rules in terms of minimizing the weighted waiting time of the patients and the penalty of emergent patients in the suggested scenarios. This study demonstrates the successful implementation of the deep RL for ED applications, particularly in assisting decision-makers under the dynamic environment of an ED.
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Camilo DGG, de Souza RP, Frazão TDC, da Costa Junior JF. Multi-criteria analysis in the health area: selection of the most appropriate triage system for the emergency care units in natal. BMC Med Inform Decis Mak 2020; 20:38. [PMID: 32085757 PMCID: PMC7035766 DOI: 10.1186/s12911-020-1054-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 02/14/2020] [Indexed: 12/04/2022] Open
Abstract
Background Multiobjective decision-making processes present a high degree of complexity in their solution, and tools such as multicriteria decision analysis appear as a way to facilitate the decision-makers’ solution and ensure that the decision is made cohesively and efficiently. In the public health sector, decisions are even more delicate because they work not only with the direct influence of human needs, but also with limited financial resources. An important point for the emergency care units is the triage system, which consists of a pre-evaluation of the patients, classifying them according to the degree of life risk. Through triage, the patient can be attended more quickly and efficiently, streamlining the whole process. Thus, the present research endeavored to determine the most appropriate triage protocol for emergency healthcare units in Natal-RN city in Brazil and may help others less advanced countries to determine the most appropriate triage protocol for emergency healthcare. Methods In this study, we used the multicriteria analysis method known as FITradeoff. In addition, interviews and structured questionnaires applied with nurses, specialists and directors. Results Based on the questionnaires and preferences presented by the decision-makers, the Spanish Triage System was the most suitable protocol for the emergency care units, which presented with high ease of use and implementation. Conclusions This study reached its main objective, which was to determine the most appropriate triage protocol. In addition, it was observed the possibility of new research, such as the development of a specific protocol for this emergency care units and the creation of an application software for this new protocol.
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Cetin-Sahin D, Ducharme F, McCusker J, Veillette N, Cossette S, Vu TTM, Vadeboncoeur A, Lachance PA, Mah R, Berthelot S. Experiences of an Emergency Department Visit Among Older Adults and Their Families: Qualitative Findings From a Mixed-Methods Study. J Patient Exp 2019; 7:346-356. [PMID: 32821794 PMCID: PMC7410141 DOI: 10.1177/2374373519837238] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Emergency department (ED) visits are critical events for older adults, but little is known regarding their experiences, particularly about their physical needs, the involvement of accompanying family members, and the transition back to the community. Objective To explore experiences of an ED visit among patients aged 75 and older. Methods In a mixed-methods study, a cohort of patients aged 75 and older (or a family member) discharged from the ED back to the community was recruited from 4 urban EDs. A week following discharge, structured telephone interviews supplemented with open-ended questions were conducted. A subsample (76 patients, 32 family members) was purposefully selected. Verbatim transcripts of responses to the open-ended questions were thematically analyzed. Results Experiences related to physical needs included comfort, equipment supporting mobility and autonomy, help when needed, and access to drink and food. Family members required opportunities to provide patient support and greater involvement in their care. At discharge, patients/families required adequate discharge education, resolution of their health problem, information on medications, and greater certainty about planned follow-up medical and home care services. Conclusions Our findings suggest several areas that could be targeted to improve patient and family perceptions of the care at an ED visit.
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Affiliation(s)
- Deniz Cetin-Sahin
- St. Mary's Research Centre, Montreal, Quebec, Canada.,McGill University, Montreal, Quebec, Canada.,Center for Research in Aging, Donald Berman Maimonides Geriatric Centre, Montreal, Quebec, Canada
| | - Francine Ducharme
- University of Montreal, Montreal, Quebec, Canada.,Research Centre, Institut universitaire de gériatrie de Montréal, Montreal, Quebec, Canada
| | - Jane McCusker
- St. Mary's Research Centre, Montreal, Quebec, Canada.,McGill University, Montreal, Quebec, Canada
| | - Nathalie Veillette
- University of Montreal, Montreal, Quebec, Canada.,Research Centre, Institut universitaire de gériatrie de Montréal, Montreal, Quebec, Canada
| | - Sylvie Cossette
- University of Montreal, Montreal, Quebec, Canada.,Montreal Heart Institute Research Center, Montreal, Quebec, Canada
| | - T T Minh Vu
- University of Montreal, Montreal, Quebec, Canada.,Research Centre, Institut universitaire de gériatrie de Montréal, Montreal, Quebec, Canada.,Centre hospitalier de l'université de Montréal, Montreal, Quebec, Canada
| | - Alain Vadeboncoeur
- University of Montreal, Montreal, Quebec, Canada.,Emergency Medicine Services, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Paul-André Lachance
- University of Montreal, Montreal, Quebec, Canada.,Hôpital de la Cité-de-la-Santé, Laval, Quebec, Canada
| | - Rick Mah
- St. Mary's Hospital Center, Montreal, Quebec, Canada
| | - Simon Berthelot
- Centre de recherche du CHU de Québec-Université Laval, Quebec, Canada
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Hasselbalch RB, Pries-Heje M, Schultz M, Plesner LL, Ravn L, Lind M, Greibe R, Jensen BN, Høi-Hansen T, Carlson N, Torp-Pedersen C, Rasmussen LS, Iversen K. The Copenhagen Triage Algorithm is non-inferior to a traditional triage algorithm: A cluster-randomized study. PLoS One 2019; 14:e0211769. [PMID: 30716123 PMCID: PMC6361446 DOI: 10.1371/journal.pone.0211769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 01/19/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Triage systems with limited room for clinical judgment are used by emergency departments (EDs) worldwide. The Copenhagen Triage Algorithm (CTA) is a simplified triage system with a clinical assessment. Methods The trial was a non-inferiority, two-center cluster-randomized crossover study where CTA was compared to a local adaptation of Adaptive Process Triage (ADAPT). CTA involves initial categorization based on vital signs with a final modification based on clinical assessment by an ED nurse. We used 30-day mortality with a non-inferiority margin at 0.5%. Predictive performance was compared using Receiver Operator Characteristics. Results We included 45,347 patient visits, 23,158 (51%) and 22,189 (49%) were triaged with CTA and ADAPT respectively with a 30-day mortality of 3.42% and 3.43% (P = 0.996) a difference of 0.01% (95% CI: -0.34 to 0.33), which met the non-inferiority criteria. Mortality at 48 hours was 0.62% vs. 0.71%, (P = 0.26) and 6.38% vs. 6.61%, (P = 0.32) at 90 days for CTA and ADAPT. CTA triaged at significantly lower urgency level (P<0.001) and was superior in predicting 30-day mortality, Area under the curve: 0.67 (95% CI 0.65–0.69) compared to 0.64 for ADAPT (95% CI 0.62–0.66) (P = 0.03). There were no significant differences in rate of admission to the intensive care unit, length of stay, waiting time nor rate of readmission within 30 or 90 days. Conclusion A novel triage system based on vital signs and a clinical assessment by an ED nurse was non-inferior to a traditional triage algorithm by short term mortality, and superior in predicting 30-day mortality. Trial registration Clinicaltrials.gov NCT02698319
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Affiliation(s)
| | - Mia Pries-Heje
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Martin Schultz
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | | | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Greibe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Thomas Høi-Hansen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Nicholas Carlson
- Department of Cardiology, Gentofte Hospital, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Health, Science and Technology, Aalborg University and Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
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Abstract
In this paper, we will present the planning and design process of a triage decision-support application, aimed to be used for both research data gathering and real-time triage decision-making. Triage is an initial classification of emergency department (ED) patients, according to the severity level of their medical condition. The need of fast and accurate triage decision-making, lead to the development of widely used triage algorithms, such as ESI (Emergency Severity Index). Observations and interviews with triage personnel exposed difficulties of triage process and helped us create an ESI-based decision making model. Next, we built a multiple-choice questioner to characterize the application and required features. 40 triage nurses completed the questioner. Results indicated that the most highly requested feature was an automated severity grade calculator, which became the core of the proposed design. While current design focuses on the analytical decision model, statistical analysis of the questioner results indicated that it is often insufficient when facing medical reality complexities, dictating nurse’s frequent use of intuition. Using triage systems data analysis and modern machine-learning methodologies, we inspire to develop a second version of the application that will integrate intuitive insights into triage scale algorithmic decision process.
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Cameron PA. Is There a Future for Emergency Medicine? HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790301000301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hammad K, Peng L, Anikeeva O, Arbon P, Du H, Li Y. Emergency nurses’ knowledge and experience with the triage process in Hunan Province, China. Int Emerg Nurs 2017; 35:25-29. [DOI: 10.1016/j.ienj.2017.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 05/26/2017] [Accepted: 05/31/2017] [Indexed: 11/16/2022]
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Hasselbalch RB, Plesner LL, Pries-Heje M, Ravn L, Lind M, Greibe R, Jensen BN, Rasmussen LS, Iversen K. The Copenhagen Triage Algorithm: a randomized controlled trial. Scand J Trauma Resusc Emerg Med 2016; 24:123. [PMID: 27724978 PMCID: PMC5057417 DOI: 10.1186/s13049-016-0312-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 09/30/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Crowding in the emergency department (ED) is a well-known problem resulting in an increased risk of adverse outcomes. Effective triage might counteract this problem by identifying the sickest patients and ensuring early treatment. In the last two decades, systematic triage has become the standard in ED's worldwide. However, triage models are also time consuming, supported by limited evidence and could potentially be of more harm than benefit. The aim of this study is to develop a quicker triage model using data from a large cohort of unselected ED patients and evaluate if this new model is non-inferior to an existing triage model in a prospective randomized trial. METHODS The Copenhagen Triage Algorithm (CTA) study is a prospective two-center, cluster-randomized, cross-over, non-inferiority trial comparing CTA to the Danish Emergency Process Triage (DEPT). We include patients ≥16 years (n = 50.000) admitted to the ED in two large acute hospitals. Centers are randomly assigned to perform either CTA or DEPT triage first and then use the other triage model in the last time period. The CTA stratifies patients into 5 acuity levels in two steps. First, a scoring chart based on vital values is used to classify patients in an immediate category. Second, a clinical assessment by the ED nurse can alter the result suggested by the score up to two categories up or one down. The primary end-point is 30-day mortality and secondary end-points are length of stay, time to treatment, admission to intensive care unit, and readmission within 30 days. DISCUSSION If proven non-inferior to standard DEPT triage, CTA will be a faster and simpler triage model that is still able to detect the critically ill. Simplifying triage will lessen the burden for the ED staff and possibly allow faster treatment. TRIAL REGISTRATION Clinicaltrials.gov: NCT02698319 , registered 24. of February 2016, retrospectively registered.
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Affiliation(s)
| | | | - Mia Pries-Heje
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Greibe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Lars S. Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
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Fontanazza S, Piccotti E, Sartini M, Cristina ML, Spagnolo AM, Palmieri A, Di Pietro P. Development of stratification criteria of green codes in a pediatric emergency department: a pilot study. Minerva Pediatr 2016; 71:21-27. [PMID: 27163394 DOI: 10.23736/s0026-4946.16.04471-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The aim of this study was to find stratification criteria in a group of children assigned to the green triage category at an emergency department (ED). METHODS We analyzed a sample of patients admitted to the ED of Gaslini Children's Hospital in Genoa between February 2014 and January 2015 who had been given a green code on triage. We analyzed the following parameters: age, sex, nationality, reason for admission, number and type of the procedures performed, length of stay in the ED, destination on discharge, color code and diagnosis on discharge. RESULTS Of the 2875 patients enrolled, 258 (8.97%) were hospitalized, 135 (4.70%) were placed in short intensive observation, 1609 (55.97%) were discharged from the ED without any intervention, 829 (28.83%) were discharged after undergoing procedures (blood tests, microbiology investigation, imaging, specialist evaluation) and 44 (1.5%) spontaneously left the ED. Among the patients who were hospitalized and those kept under short intensive observation, the most frequent discharge diagnosis was gastrointestinal disease; among those patients discharged with and without undergoing procedures, the most frequent diagnosis was respiratory disease. The mean age of patients admitted to hospital and of those discharged without undergoing procedures was 46 months, while the mean ages of patients kept under short intensive observation and of those discharged after undergoing procedures were 54 and 61 months, respectively. CONCLUSIONS These preliminary results suggest that one of the main criteria of stratification of green codes on triage is the association between 2 variables: age and pathology.
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Affiliation(s)
- Silvia Fontanazza
- Department of Pediatric Emergency, "G. Gaslini" Children's Hospital, Genoa, Italy
| | - Emanuela Piccotti
- Department of Pediatric Emergency, "G. Gaslini" Children's Hospital, Genoa, Italy
| | - Marina Sartini
- Department of Health Sciences, University of Genoa, Genoa, Italy -
| | - Maria L Cristina
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Anna M Spagnolo
- Department of Health Sciences, University of Genoa, Genoa, Italy
| | - Antonella Palmieri
- Department of Pediatric Emergency, "G. Gaslini" Children's Hospital, Genoa, Italy
| | - Pasquale Di Pietro
- Department of Pediatric Emergency, "G. Gaslini" Children's Hospital, Genoa, Italy
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Physician workload and the Canadian Emergency Department Triage and Acuity Scale: the Predictors of Workload in the Emergency Room (POWER) Study. CAN J EMERG MED 2015; 11:321-9. [DOI: 10.1017/s1481803500011350] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTIntroduction:The Canadian Emergency Department Triage and Acuity Scale (CTAS) is a 5-level triage tool used to determine the priority by which patients should be treated in Canadian emergency departments (EDs). To determine emergency physician (EP) workload and staffing needs, many hospitals in Ontario use a case-mix formula based solely on patient volume at each triage level. The purpose of our study was to describe the distribution of EP time by activity during a shift in order to estimate the amount of time required by an EP to assess and treat patients in each triage category and to determine the variability in the distribution of CTAS scoring between hospital sites.Methods:Research assistants directly observed EPs for 592 shifts and electronically recorded their activities on a moment-by-moment basis. The duration of all activities associated with a given patient were summed to derive a directly observed estimate of the amount of EP time required to treat the patient.Results:We observed treatment times for 11 716 patients in 11 hospital-based EDs. The mean time for physicians to treat patients was 73.6 minutes (95% confidence interval [CI] 63.6–83.7) for CTAS level 1, 38.9 minutes (95% CI 36.0–41.8) for CTAS-2, 26.3 minutes (95% CI 25.4–27.2) for CTAS-3, 15.0 minutes (95% CI 14.6–15.4) for CTAS-4 and 10.9 minutes (95% CI 10.1–11.6) for CTAS-5. Physician time related to patient care activities accounted for 84.2% of physicians' ED shifts.Conclusion:In our study, EPs had very limited downtime. There was significant variability in the distribution of CTAS scores between sites and also marked variation in EP time related to each triage category. This brings into question the appropriateness of using CTAS alone to determine physician staffing levels in EDs.
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A door-to-needle time of 30 minutes or less for myocardial infarction thrombolysis is possible in rural emergency departments. CAN J EMERG MED 2015; 10:429-33. [DOI: 10.1017/s1481803500010502] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjective:The Canadian Emergency Cardiac Care Coalition, the American Heart Association and similar groups have established a benchmark for the administration of thrombolytics in acute myocardial infarction (AMI) care as a door-to-needle (DTN) time of 30 minutes or less. Previous research suggests that this goal is not being achieved in Canada. The purpose of this study was to determine whether the target DTN time of 30 minutes or less for thrombolysis could be met in 2 rural Ontario emergency departments (EDs).Methods:We conducted a retrospective chart review and obtained descriptive data for each case, including demographic information and the Canadian Emergency Department Triage and Acuity Scale (CTAS) score. Visit timeline data were also collected and included the time during which patients saw a physician, had an electrocardiogram (ECG), received thrombolytic therapy and were discharged from the ED. Relevant time intervals, such as the median DTN time, were calculated.Results:A total of 454 charts were reviewed for patients with a diagnosis of AMI who were seen between 1996 and 2007. The final sample consisted of 101 patients who received thrombolytics (63% men) whose median age was 67 years and median CTAS score was Level II (Emergent). The median door-to-ECG time was 6 minutes, door-to-physician time was 8 minutes and DTN time was 27 minutes; 58% of patients received thrombolytics within 30 minutes.Conclusion:A DTN time of 30 minutes or less is achievable in rural EDs.
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Interrater agreement of Canadian Emergency Department Triage and Acuity Scale scores assigned by base hospital and emergency department nurses. CAN J EMERG MED 2015; 12:45-9. [DOI: 10.1017/s148180350001201x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
ABSTRACTObjective:We sought to assess the applicability of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in the prehospital setting by comparing CTAS scores assigned during ambulance transportation by base hospital (BH) nurses with CTAS scores given by emergency department (ED) nurses on patients' arrival.Methods:We recruited a prospective sample of consecutive patients who were transported to the ED by ambulance between December 2006 and March 2007 for whom a contact was made with the BH. Patients were triaged by the BH nurse with online communication and vital signs transmission. On arrival, patients were blindly triaged again by the ED nurse. We used the quadratic weighted κ statistic to measure the agreement between the 2 CTAS scores.Results:Ninety-four patients were triaged twice by 2 nursing teams (9 nurses at the BH and 39 nurses in the ED). The agreement obtained on prehospital and ED CTAS scores was moderate (κ = 0.50; 95% confidence interval 0.37–0.63).Conclusion:The moderate interrater agreement we obtained may be a result of the changing conditions of patients during transport or may indicate that CTAS scoring requires direct contact to produce reliable triage scores. Our study casts a serious doubt on the appropriateness of BH nurses performing triage with CTAS in the prehospital setting.
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Abstract
ABSTRACTBackground:A variety of models are used by hospitals, provincial governments, and departments of emergency medicine to “predict” the number of physician hours of coverage necessary to staff emergency departments. These models have arisen to meet specific requirements—some for the purpose of determining hourly rates of compensation, others to determine the amount of funding that will be provided to “purchase” physician coverage, and others to determine the number of hours of coverage necessary to maintain patient waits within “acceptable” limits. All such models have their strengths and weaknesses and have been criticized as not reflecting the “real” needs of any given department.Objective:In the article that follows, a review of existing models is presented, annotating their strengths and weaknesses to derive the characteristics of an “ideal” workload model.Conclusion:None of the models currently used to measure emergency department workload can be relied on to accurately predict the number of staffed hours necessary. Models that may achieve this objective are suggested.
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Affiliation(s)
- Isser Dubinsky
- Department of Family and Community Medicine, University of Toronto, Toronto, ON.
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Peng L, Hammad K. Current status of emergency department triage in mainland China: A narrative review of the literature. Nurs Health Sci 2014; 17:148-58. [PMID: 25196171 DOI: 10.1111/nhs.12159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Revised: 06/04/2014] [Accepted: 06/08/2014] [Indexed: 01/24/2023]
Abstract
In this review, the current status of emergency department triage in mainland China is explored, with the purpose of generating a deeper understanding of the topic. Literature was identified through electronic databases, and was included for review if published between 2002 and 2012, included significant discussion of daily emergency department triage in mainland China, was peer reviewed, and published in English or Chinese. Thematic analysis was used to identify themes which emerged from the reviewed literature. This resulted in 21 articles included for review. Four themes emerged from the review: triage process, triage training, qualification of triage nurses, and quality of triage. The review demonstrates that there is currently not a unified approach to emergency department triage in mainland China. Additionally, there are limitations in triage training for nurses and confusion around the role of triage nurses. This review highlights that emergency department triage in mainland China is still in its infancy and that more research is needed to further develop the role of triage.
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Affiliation(s)
- Lingli Peng
- Department of Orthopedics, Xiangya Hospital, Central South University, Changsha, Hunan province, China
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Melon KA, White D, Rankin J. Beat the clock! Wait times and the production of 'quality' in emergency departments. Nurs Philos 2014; 14:223-37. [PMID: 23745663 DOI: 10.1111/nup.12022] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Emergency care in large urban hospitals across the country is in the midst of major redesign intended to deliver quality care through improved access, decreased wait times, and maximum efficiency. The central argument in this paper is that the conceptualization of quality including the documentary facts and figures produced to substantiate quality emergency care is socially organized within a powerful ruling discourse that inserts the interests of politics and economics into nurses' work. The Canadian Triage and Acuity Scale figures prominently in the analysis as a high-level organizer of triage work and knowledge production that underpins the way those who administer the system define, measure and evaluate emergency care processes, and then use this information for restructuring. Managerial targets and thinking not only dominate the way emergency work is understood, determined, and controlled but also subsume the actual work of health-care providers in spaces called 'wait times', where it is systematically rendered 'unknowable'. The analysis is supported with evidence from an extensive institutional ethnography that shows what nurses actually do to manage the safe passage of patients through their emergency care process starting with the work of triage nurses.
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Affiliation(s)
- Karen A Melon
- Alberta Health Services, 351 Rundlelawn Road NE, Calgary, Alberta, Canada.
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Kiss V, Pim C, Hemmelgarn BR, Quan H. Building knowledge about health services utilization by refugees. J Immigr Minor Health 2013; 15:57-67. [PMID: 21959711 DOI: 10.1007/s10903-011-9528-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
The objective of this study was to compare the utilization of outpatient physician, emergency department and hospital services between refugees and the general population in Calgary, Alberta. Data was collected on 2,280 refugees from a refugee clinic in Calgary and matched with 9,120 non-refugees. Both groups were linked to Alberta Health and Wellness administrative data to assess health services utilization over 2 years. After adjusting for age, sex and medical conditions, refugees utilized general practitioners, emergency departments and hospitals more than non-refugees. A similar proportion in the two groups had seen a general practitioner within 1 week prior to their emergency department visit; however, refugees were more likely to have been triaged for urgent conditions and female refugees seen for pregnancy-related conditions than non-refugees. Refugees were more likely to have had infectious and parasitic diseases. Refugees utilized health services more than non-refugees with no evidence of underutilization.
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Affiliation(s)
- Valerie Kiss
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, TRW Building, 3rd Floor, 3280 Hospital Drive NW, Calgary, AB T2N 4Z6, Canada
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Patient safety analysis of the ED care of patients with heart failure and COPD exacerbations: a multicenter prospective cohort study. Am J Emerg Med 2013; 32:29-35. [PMID: 24139995 DOI: 10.1016/j.ajem.2013.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Revised: 09/07/2013] [Accepted: 09/16/2013] [Indexed: 10/26/2022] Open
Abstract
OBJECTIVES For emergency department (ED) patients with acute exacerbations of heart failure and chronic obstructive pulmonary disease (COPD), we aimed to assess the adherence to evidence-based care and determine the proportion that experienced adverse events. METHODS An expert panel identified critical actions for ED care of heart failure and COPD patients based on clinical practice guidelines. We collected outcome data for discharged ED patients >age 50 with acute heart failure or COPD in a multicenter prospective cohort study at five academic EDs. We measured 3 flagged outcomes: return ED visit, admission, or death within 14 days. Three trained physician reviewers reviewed case summaries for adverse event determination (flagged outcomes related to healthcare received). We evaluated health records for adherence to the critical actions for each condition. RESULTS We identified 122 (7.0%) flagged outcomes among 1,718 enrolled patients (61 heart failure, 59 COPD and 2 dual diagnoses). The mean age was 74.2 (SD 10.4) and 44.3% were female. Among 10 critical actions for heart failure and 13 for COPD, a mean proportion of 9.4/10 and 11.0/13 were adhered to respectively. We identified 12 adverse events (9.8%, 95%CI: 5.6-16.5%), all of which were deemed preventable, including 1 death. The most common contributors were unsafe disposition decisions (10/12, 83.3%) and diagnostic issues (5/12, 41.7%). Patients who died with heart failure were statistically significantly less likely to have guideline adherent care (P = .02). CONCLUSIONS A small proportion of return ED visits were related to index care. We believe there is need for improvement around disposition decision making for both conditions to reduce the highly preventable and clinically significant adverse events we found.
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Quality in triage: indicators in patients with respiratory disease. Pediatr Emerg Care 2013; 29:710-4. [PMID: 23714756 DOI: 10.1097/pec.0b013e3182949042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES The objective was to apply quality indicators in respiratory disease triage during a set time period. METHODS This was a retrospective, descriptive, and comparative study of all patients attending the emergency department of Acosta Ñu Children's Hospital with breathing difficulty, between January 1 and July 31, 2011. RESULTS Two thousand five hundred eighty-two patients were included in the study. The delay in medical care according to severity of breathing difficulty was as follows: for critical patients, 1 minute (100% compliance); for emergencies, 6.4 minutes (93.4% compared with 95% standard); for urgencies, 15.8 minutes (90% compared with the standard 90%); and for semiurgencies, 35 minutes (92.4% vs. 85% standard). Regarding to the admission-triage time indicator: mean time was 6.1 minutes; 2220 patients (86%) were classified in less than 10 minutes from the time of hospital admission, and 2453 (95%) were evaluated before 15 minutes. Respiratory rate was recorded in 2368 patients (91.7%), and pulse oximetry in 2443 (94.6%). Both parameters were recorded in 2271 children (88%). Errors in classification were detected, mainly tendency to underestimate the risk or exacerbate the clinical situation; 441 patients underwent subtriage (20.5%), and 44 overtriage (1.7%). There were drawbacks to classify emergencies error rate 45.8% (P < 0.00001). Relationship between pathophysiologic diagnosis and triage level was significant (P < 0.00001). CONCLUSIONS Indicators of triage quality were acceptably met in respiratory disease. Breathing difficulty was identified and classified as urgent, although problems arouse at differentiation between moderate and severe dyspnea.
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Can Emergency Nurses' Triage Skills Be Improved by Online Learning? Results of an Experiment. J Emerg Nurs 2013; 39:20-6. [DOI: 10.1016/j.jen.2011.07.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Revised: 06/30/2011] [Accepted: 07/07/2011] [Indexed: 11/23/2022]
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Abstract
AbstractTriage is a complex process and is one means for determining which patients most need access to limited resources. Triage has been studied extensively, particularly in relation to triage in overcrowded emergency departments, where individuals presenting for treatment often are competing for the available stretchers. Research also has been done in relation to the use of prehospital and field triage during mass-casualty incidents and disasters.In contrast, scant research has been done to develop and test an effective triage approach for use in mass-gathering and mass-participation events, although there is a growing body of knowledge regarding the health needs of persons attending large events. Existing triage and acuity scoring systems are suboptimal for this unique population, as these events can involve high patient presentation rates (PPR) and, occasionally, critically ill patients. Mass-gathering events are dangerous; a higher incidence of injury occurs than would be expected from general population statistics.The need for an effective triage and acuity scoring system for use during mass gatherings is clear, as these events not only create multiple patient encounters, but also have the potential to become mass-casualty incidents. Furthermore, triage during a large-scale disaster or mass-casualty incident requires that multiple, local agencies work together, necessitating a common language for triage and acuity scoring.In reviewing existing literature with regard to triage systems that might be employed for this population, it is noted that existing systems are biased toward traumatic injuries, usually ignoring mitigating factors such as alcohol and drug use and environmental exposures. Moreover, there is a substantial amount of over-triage that occurs with existing prehospital triage systems, which may lead to misallocation of limited resources. This manuscript presents a review of the available literature and proposes a triage system for use during mass gatherings that also may be used in the setting of mass-casualty incidents or disaster responses.TurrisSA, LundA. Triage during mass gatherings. Prehosp Disaster Med. 2012;27(6):1-5.
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Sung SF, Huang YC, Ong CT, Chen W. Validity of a computerised five-level emergency triage system for patients with acute ischaemic stroke. Emerg Med J 2012; 30:454-8. [DOI: 10.1136/emermed-2012-201423] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Ruys LJ, Gunning M, Teske E, Robben JH, Sigrist NE. Evaluation of a veterinary triage list modified from a human five-point triage system in 485 dogs and cats. J Vet Emerg Crit Care (San Antonio) 2012; 22:303-12. [DOI: 10.1111/j.1476-4431.2012.00736.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Laura J. Ruys
- Medisch Centrum voor Dieren [Animal Medical Center]; Isolatorweg 45 1014 AS Amsterdam The Netherlands
- Department of Veterinary Clinical Medicine; Vetsuisse Faculty of Bern; Bern Switzerland
| | - Myrna Gunning
- Medisch Centrum voor Dieren [Animal Medical Center]; Isolatorweg 45 1014 AS Amsterdam The Netherlands
| | - Erik Teske
- Department of Clinical Sciences of Companion Animals; Faculty of Veterinary Medicine; Utrecht University; The Netherlands
| | - Joris H. Robben
- Department of Clinical Sciences of Companion Animals; Faculty of Veterinary Medicine; Utrecht University; The Netherlands
| | - Nadja E. Sigrist
- Department of Veterinary Clinical Medicine; Vetsuisse Faculty of Bern; Bern Switzerland
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Dallaire C, Poitras J, Aubin K, Lavoie A, Moore L. Emergency department triage: do experienced nurses agree on triage scores? J Emerg Med 2011; 42:736-40. [PMID: 22209550 DOI: 10.1016/j.jemermed.2011.05.085] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 10/11/2010] [Accepted: 05/25/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND The reproducibility of the Canadian Triage & Acuity Scale (CTAS), designed and introduced in the late 1990s in all Canadian emergency departments (EDs), has been studied mostly using measures of interrater agreement. However, each of these studies shares a common limitation: the nurses had received fresh CTAS training, which is likely to have led to an overestimation of the reproducibility of CTAS. OBJECTIVES This study aims to assess the interrater reliability of the CTAS in current clinical practice, that is, as used by experienced ED nurses without recent certification or recertification. METHODS A prospective sample of 100 patients arriving by ambulance was identified and yielded a set of 100 written scenarios. Five experienced ED nurses reviewed and blindly assigned a CTAS score to each scenario. The agreement among nurses was measured using the Kappa statistic calculated with quadratic weights. Kappa values were generated for each pair of nurses and a global Kappa coefficient was calculated to measure overall agreement. RESULTS Overall interrater agreement was moderate, with a global Kappa of 0.44 (95% confidence interval 0.40-0.48). However, pairwise, Kappa values were heterogeneous (0.30 to 0.61, p=0.0013). CONCLUSIONS The moderate interrater agreement observed in this study is disappointingly low and suggests that CTAS reliability may be lower than expected, and this warrants further research. Intra-observer reliability of CTAS should be ascertained more extensively among experienced nurses, and a future evaluation should involve several institutions.
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O'Toole TP, Pirraglia PA, Dosa D, Bourgault C, Redihan S, O'Toole MB, Blumen J. Building care systems to improve access for high-risk and vulnerable veteran populations. J Gen Intern Med 2011; 26 Suppl 2:683-8. [PMID: 21989622 PMCID: PMC3191220 DOI: 10.1007/s11606-011-1818-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND For many high-risk patients, accessing primary care is challenged by competing needs and priorities, socioeconomics, and other circumstances. The resulting lack of treatment engagement makes these vulnerable patient populations susceptible to poor health outcomes and an over-reliance on emergency department-based care. METHODS We describe a quasi-experimental pre-post study examining a vulnerable population-based application of the patient-centered medical home applied to four high-risk groups: homeless veterans, cognitively impaired elderly, women veterans and patients with serious mental illness. We measured 6-month primary care, emergency department and inpatient care use and chronic disease management when care was based in a general internal medicine clinic (2006) and in a population-specific medical home (2008). RESULTS Overall 457 patients were studied, assessing care use and outcomes for the last 6 months in each study year. Compared with 2006, in 2008 there was a significant increase in primary care use (p < 0.001) and improvement in chronic disease monitoring and diabetes control (2006 HBA1C: 8.5 vs. 2008 HBA1C 6.9) in all four groups. However, there was also an increase in both emergency department use and hospitalizations, albeit with shorter lengths of stay in 2008 compared with 2006. Most of the increased utilization was driven by a small proportion of patients in each group. CONCLUSION Tailoring the medical home model to the specific needs and challenges facing high-risk populations can increase primary care utilization and improve chronic disease monitoring and diabetes management. More work is needed in directing this care model to reducing emergency department and inpatient use.
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Affiliation(s)
- Thomas P O'Toole
- Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI 02918, USA. Thomas.O'
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Blanchard IE, Doig CJ, Hagel BE, Anton AR, Zygun DA, Kortbeek JB, Powell DG, Williamson TS, Fick GH, Innes GD. Emergency medical services response time and mortality in an urban setting. PREHOSP EMERG CARE 2011; 16:142-51. [PMID: 22026820 DOI: 10.3109/10903127.2011.614046] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND A common tenet in emergency medical services (EMS) is that faster response equates to better patient outcome, translated by some EMS operations into a goal of a response time of 8 minutes or less for advanced life support (ALS) units responding to life-threatening events. OBJECTIVE To explore whether an 8-minute EMS response time was associated with mortality. METHODS This was a one-year retrospective cohort study of adults with a life-threatening event as assessed at the time of the 9-1-1 call (Medical Priority Dispatch System Echo- or Delta-level event). The study setting was an urban all-ALS EMS system serving a population of approximately 1 million. Response time was defined as 9-1-1 call receipt to ALS unit arrival on scene, and outcome was defined as all-cause mortality at hospital discharge. Potential covariates included patient acuity, age, gender, and combined scene and transport interval time. Stratified analysis and logistic regression were used to assess the response time-mortality association. RESULTS There were 7,760 unit responses that met the inclusion criteria; 1,865 (24%) were ≥8 minutes. The average patient age was 56.7 years (standard deviation = 21.5). For patients with a response time ≥8 minutes, 7.1% died, compared with 6.4% for patients with a response time ≤7 minutes 59 seconds (risk difference 0.7%; 95% confidence interval [CI]: -0.5%, 2.0%). The adjusted odds ratio of mortality for ≥8 minutes was 1.19 (95% CI: 0.97, 1.47). An exploratory analysis suggested there may be a small beneficial effect of response ≤7 minutes 59 seconds for those who survived to become an inpatient (adjusted odds ratio = 1.30; 95% CI: 1.00, 1.69). CONCLUSIONS These results call into question the clinical effectiveness of a dichotomous 8-minute ALS response time on decreasing mortality for the majority of adult patients identified as having a life-threatening event at the time of the 9-1-1 call. However, this study does not suggest that rapid EMS response is undesirable or unimportant for certain patients. This analysis highlights the need for further research on who may benefit from rapid EMS response, whether these individuals can be identified at the time of the 9-1-1 call, and what the optimum response time is.
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Affiliation(s)
- Ian E Blanchard
- Emergency Medical Services, Alberta Health Services, Calgary, Alberta, Canada
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