Implementation and refinement of the emergency severity index

Deep continual learning for medical call incidents text classification under the presence of dataset shifts

The aim of this work is to develop and evaluate a deep classifier that can effectively prioritize Emergency Medical Call Incidents (EMCI) according to their life-threatening level under the presence of dataset shifts. We utilized a dataset consisting of 1982746 independent EMCI instances obtained from the Health Services Department of the Region of Valencia (Spain), with a time span from 2009 to 2019 (excluding 2013). The dataset includes free text dispatcher observations recorded during the call, as well as a binary variable indicating whether the event was life-threatening. To evaluate the presence of dataset shifts, we examined prior probability shifts, covariate shifts, and concept shifts. Subsequently, we designed and implemented four deep Continual Learning (CL) strategies-cumulative learning, continual fine-tuning, experience replay, and synaptic intelligence-alongside three deep CL baselines-joint training, static approach, and single fine-tuning-based on DistilBERT models. Our results demonstrated evidence of prior probability shifts, covariate shifts, and concept shifts in the data. Applying CL techniques had a statistically significant (α=0.05) positive impact on both backward and forward knowledge transfer, as measured by the F1-score, compared to non-continual approaches. We can argue that the utilization of CL techniques in the context of EMCI is effective in adapting deep learning classifiers to changes in data distributions, thereby maintaining the stability of model performance over time. To our knowledge, this study represents the first exploration of a CL approach using real EMCI data.

Leveraging graph neural networks for supporting automatic triage of patients

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.

Interpretable Deep Learning System for Identifying Critical Patients Through the Prediction of Triage Level, Hospitalization, and Length of Stay: Prospective Study

BACKGROUND

Triage is the process of accurately assessing patients' symptoms and providing them with proper clinical treatment in the emergency department (ED). While many countries have developed their triage process to stratify patients' clinical severity and thus distribute medical resources, there are still some limitations of the current triage process. Since the triage level is mainly identified by experienced nurses based on a mix of subjective and objective criteria, mis-triage often occurs in the ED. It can not only cause adverse effects on patients, but also impose an undue burden on the health care delivery system.

OBJECTIVE

Our study aimed to design a prediction system based on triage information, including demographics, vital signs, and chief complaints. The proposed system can not only handle heterogeneous data, including tabular data and free-text data, but also provide interpretability for better acceptance by the ED staff in the hospital.

METHODS

In this study, we proposed a system comprising 3 subsystems, with each of them handling a single task, including triage level prediction, hospitalization prediction, and length of stay prediction. We used a large amount of retrospective data to pretrain the model, and then, we fine-tuned the model on a prospective data set with a golden label. The proposed deep learning framework was built with TabNet and MacBERT (Chinese version of bidirectional encoder representations from transformers [BERT]).

RESULTS

The performance of our proposed model was evaluated on data collected from the National Taiwan University Hospital (901 patients were included). The model achieved promising results on the collected data set, with accuracy values of 63%, 82%, and 71% for triage level prediction, hospitalization prediction, and length of stay prediction, respectively.

CONCLUSIONS

Our system improved the prediction of 3 different medical outcomes when compared with other machine learning methods. With the pretrained vital sign encoder and repretrained mask language modeling MacBERT encoder, our multimodality model can provide a deeper insight into the characteristics of electronic health records. Additionally, by providing interpretability, we believe that the proposed system can assist nursing staff and physicians in taking appropriate medical decisions.

Triage: A Global Perspective

Triage is a process by which patients are assessed, classified, and sorted based on their presenting complaint and clinical urgency, providing assurance for timely access to emergency care. The goal is to get the right person to the right place, in the right amount of time, for the right reason, and within the context of resource availability. In many countries, a standardized triage system, underpinned through the use of guidelines, is used to provide clinicians with support and guidance. Triage is a globally adopted principle, and although triage guidelines are used in many countries, no single system has been internationally adopted. This paper discusses the importance of how triage process standardization improves patient care, resource management, and benchmarking at local, national, and international levels by applying 5 internationally recognized triage systems to fictional case studies. Evaluation of similarities and differences in severity scores, with a gap analysis, occurs.

Predictive Value of PRISMA-7, qSOFA, ESI, and CFS for 28-Day Mortality in Elderly Patients in the Emergency Department

Background

To explore the predictive value of the Programme on Research for Integrating Services for the Maintenance of Autonomy 7 (PRISMA-7), quick Sequential Organ Failure Assessment (qSOFA) score, Emergency Severity Index (ESI), and Clinical Frailty Scale (CFS) on the 28-day mortality risk in emergency elderly patients.

Methods

A multicenter prospective observational study was conducted to select elderly patients (≥65 years old) admitted to the emergency department of three Grade-A hospitals in different regions of China from January 2020 to March 2022. Primary data were collected at the time of admission. All patients were followed up for 28 days. The primary outcome was 28-day mortality. The predictive value of four scoring systems for 28-day mortality in elderly emergency patients was assessed by receiver operating characteristic (ROC) and logistic regression analysis.

Results

A total of 687 elderly emergency patients were enrolled, of whom 66 (9.61%) died within 28 days. Age, ICU admission rate, PRISMA-7, qSOFA, and CFS were significantly higher in the death group than in the survival group (P < 0.05), and ESI was lower than in the survival group (P < 0.001). The AUC for CFS was the largest of the four scoring systems at 0.80. According to the Youden index, the optimal cutoff values for PRISMA-7, qSOFA, ESI, and CFS were >3.5, >0.5, <2.5, and >4.5, respectively. Logistic regression revealed that qSOFA and CFS were the primary risk factors for increased 28-day mortality in elderly emergency patients (P < 0.001). The combined predictor L (L=X1+0.50X2, X1 and X2 are qSOFA and CFS values, respectively) had an AUC of 0.86 and a cutoff value >2.75.

Conclusion

PRISMA-7, qSOFA, ESI, CFS, and the combined qSOFA+CFS predictor were all effective predictors of 28-day mortality risk in elderly emergency patients, with the combined qSOFA+CFS predictor having the best predictive power.

Using Machine Learning to Predict Hospital Disposition With Geriatric Emergency Department Innovation Intervention

STUDY OBJECTIVE

The Geriatric Emergency Department Innovations (GEDI) program is a nurse-based geriatric assessment and care coordination program that reduces preventable admissions for older adults. Unfortunately, only 5% of older adults receive GEDI care because of resource limitations. The objective of this study was to predict the likelihood of hospitalization accurately and consistently with and without GEDI care using machine learning models to better target patients for the GEDI program.

METHODS

We performed a cross-sectional observational study of emergency department (ED) patients between 2010 and 2018. Using propensity-score matching, GEDI patients were matched to other older adult patients. Multiple models, including random forest, were used to predict hospital admission. Multiple second-layer models, including random forest, were then used to predict whether GEDI assessment would change predicted hospital admission. Final model performance was reported as the area under the curve using receiver operating characteristic models.

RESULTS

We included 128,050 patients aged over 65 years. The random forest ED disposition model had an area under the curve of 0.774 (95% confidence interval [CI] 0.741 to 0.806). In the random forest GEDI change-in-disposition model, 24,876 (97.3%) ED visits were predicted to have no change in disposition with GEDI assessment, and 695 (2.7%) ED visits were predicted to have a change in disposition with GEDI assessment.

CONCLUSION

Our machine learning models could predict who will likely be discharged with GEDI assessment with good accuracy and thus select a cohort appropriate for GEDI care. In addition, future implementation through integration into the electronic health record may assist in selecting patients to be prioritized for GEDI care.

Effectiveness, safety, and efficiency of a drive-through care model as a response to the COVID-19 testing demand in the United States

Objectives

Here we report the clinical performance of COVID-19 curbside screening with triage to a drive-through care pathway versus main emergency department (ED) care for ambulatory COVID-19 testing during a pandemic. Patients were evaluated from cars to prevent the demand for testing from spreading COVID-19 within the hospital.

Methods

We examined the effectiveness of curbside screening to identify patients who would be tested during evaluation, patient flow from screening to care team evaluation and testing, and safety of drive-through care as 7-day ED revisits and 14-day hospital admissions. We also compared main ED efficiency versus drive-through care using ED length of stay (EDLOS). Standardized mean differences (SMD) >0.20 identify statistical significance.

Results

Of 5931 ED patients seen, 2788 (47.0%) were walk-in patients. Of these patients, 1111 (39.8%) screened positive for potential COVID symptoms, of whom 708 (63.7%) were triaged to drive-through care (with 96.3% tested), and 403 (36.3%) triaged to the main ED (with 90.5% tested). The 1677 (60.2%) patients who screened negative were seen in the main ED, with 440 (26.2%) tested. Curbside screening sensitivity and specificity for predicting who ultimately received testing were 70.3% and 94.5%. Compared to the main ED, drive-through patients had fewer 7-day ED revisits (3.8% vs 12.5%, SMD = 0.321), fewer 14-day hospital readmissions (4.5% vs 15.6%, SMD = 0.37), and shorter EDLOS (0.56 vs 5.12 hours, SMD = 1.48).

Conclusion

Curbside screening had high sensitivity, permitting early respiratory isolation precautions for most patients tested. Low ED revisit, hospital readmissions, and EDLOS suggest drive-through care, with appropriate screening, is safe and efficient for future respiratory illness pandemics.

Real-Time Patient Portal Use Among Emergency Department Patients: An Open Results Study

OBJECTIVES

We characterized real-time patient portal test result viewing among emergency department (ED) patients and described patient characteristics overall and among those not enrolled in the portal at ED arrival.

METHODS

Our observational study at an academic ED used portal log data to trend the proportion of adult patients who viewed results during their visit from May 04, 2021 to April 04, 2022. Correlation was assessed visually and with Kendall's τ. Covariate analysis using binary logistic regression assessed result(s) viewed as a function of time accounting for age, sex, ethnicity, race, language, insurance status, disposition, and social vulnerability index (SVI). A second model only included patients not enrolled in the portal at arrival. We used random forest imputation to account for missingness and Huber-White heteroskedasticity-robust standard errors for patients with multiple encounters (α = 0.05).

RESULTS

There were 60,314 ED encounters (31,164 unique patients). In 7,377 (12.2%) encounters, patients viewed results while still in the ED. Patients were not enrolled for portal use at arrival in 21,158 (35.2%) encounters, and 927 (4.4% of not enrolled, 1.5% overall) subsequently enrolled and viewed results in the ED. Visual inspection suggests an increasing proportion of patients who viewed results from roughly 5 to 15% over the study (Kendall's τ = 0.61 [p <0.0001]). Overall and not-enrolled models yielded concordance indices (C) of 0.68 and 0.72, respectively, with significant overall likelihood ratio χ 2 (p <0.0001). Time was independently associated with viewing results in both models after adjustment. Models revealed disparate use between age, race, ethnicity, SVI, sex, insurance status, and disposition groups.

CONCLUSION

We observed increased portal-based test result viewing among ED patients over the year since the 21st Century Cures act went into effect, even among those not enrolled at arrival. We observed disparities in those who viewed results.

Physician gestalt for emergency department triage: A prospective videotaped study

OBJECTIVE

Appropriate triage in patients presenting to the emergency department (ED) is often challenging. Little is known about the role of physician gestalt in ED triage. We aimed to compare the accuracy of emergency physician gestalt against the currently used computerized triage process.

METHODS

We conducted a prospective observational study in the ED at an academic medical center. Adult patients aged ≥20 years were included and underwent a standard triage protocol. The patients underwent system-based triage using the computerized software the Taiwan Triage and Acuity Scale. The entire triage process was recorded, and triage data were collected. Five physician raters provided triage levels (physician-based) according to their perceived urgency after reviewing videos. The primary outcome was hospital admission. The secondary outcomes were ED length of stay (EDLOS) and charges.

RESULTS

In total, 656 patients were recruited (mean age 52 years, 50% male). The median system-based triage level was 3. By contrast, the median physician-based triage level was 4. The physician raters tended to provide lower triage levels than the system, with an average difference of 1. There was modest concordance between the two triage methods (correlation coefficient 0.30), with a weighted kappa coefficient of 0.18. The area under the receiver operating curve for the system- and physician-based triage in predicting hospital admission were similar (0.635 vs. 0.631, p = 0.896). Attending physicians appeared to have better performance than residents in predicting admission. The variation explained (R² ) in EDLOS and charges were similar between the two triage methods (R²  = 3% for EDLOS, 7%-9% for charges).

CONCLUSIONS

Emergency physician gestalt for triage showed similar performance to a computerized system; however, physicians redistributed patients to lower triage levels. Physician gestalt has advantages for identifying low-risk patients. This approach may avoid undue time pressure for health care providers and promote rapid discharge.

The palliative care triage system in advanced cancer emergency care: development and initial validation

OBJECTIVE

We aimed to develop and validate a new emergency triage tool for use on patients with cancer undergoing palliative care (PC).

METHODS

In phase I, the new tool was developed after literature review and expert committee meetings. A prospective longitudinal study in phase II assessed the interobserver reliability of the tool. In phase III, a retrospective study of administrative data, the feasibility of routine use of the new tool and the associations with hospitalisation and survival times were evaluated.

RESULTS

The palliative care triage system (PCTS) was composed of check-list items and four colour-coded categories for maximum response time. In phase II, the PCTS was independently evaluated by two nurses for 102 attendances in the emergency department of the PC unit. An absolute agreement of 87.3% and a weighted kappa of 0.81 were observed. In phase III, all 493 attendances had the PCTS assessment registered in the medical records. The PCTS categories were associated with hospital admission (p<0.001) and survival times (p<0.001).

CONCLUSION

PCTS is a feasible tool to be used in routine ED triage of patients with advanced cancer undergoing PC. It is a valid instrument for predicting hospital admission rates and survival with high interobserver concordance rates.

Prediction across healthcare settings: a case study in predicting emergency department disposition

Several approaches exist today for developing predictive models across multiple clinical sites, yet there is a lack of comparative data on their performance, especially within the context of EHR-based prediction models. We set out to provide a framework for prediction across healthcare settings. As a case study, we examined an ED disposition prediction model across three geographically and demographically diverse sites. We conducted a 1-year retrospective study, including all visits in which the outcome was either discharge-to-home or hospitalization. Four modeling approaches were compared: a ready-made model trained at one site and validated at other sites, a centralized uniform model incorporating data from all sites, multiple site-specific models, and a hybrid approach of a ready-made model re-calibrated using site-specific data. Predictions were performed using XGBoost. The study included 288,962 visits with an overall admission rate of 16.8% (7.9–26.9%). Some risk factors for admission were prominent across all sites (e.g., high-acuity triage emergency severity index score, high prior admissions rate), while others were prominent at only some sites (multiple lab tests ordered at the pediatric sites, early use of ECG at the adult site). The XGBoost model achieved its best performance using the uniform and site-specific approaches (AUC = 0.9–0.93), followed by the calibrated-model approach (AUC = 0.87–0.92), and the ready-made approach (AUC = 0.62–0.85). Our results show that site-specific customization is a key driver of predictive model performance.

Validation of the National Early Warning Score (NEWS)-2 for adults in the emergency department in a tertiary-level clinic in Colombia: Cohort study

The National Early Warning Score (NEWS)-2 is an early warning scale that is used in emergency departments to identify patients at risk of clinical deterioration and to help establish rapid and timely management. The objective of this study was to determine the validity and prediction of mortality using the NEWS2 scale for adults in the emergency department of a tertiary clinic in Colombia.A prospective observational study was conducted between August 2018 and June 2019 at the Universidad de La Sabana Clinic.The nursing staff in the triage classified the patients admitted to the emergency room according to Emergency Severity Index and NEWS2. Demographic data, physiological variables, admission diagnosis, mortality outcome, and comorbidities were extracted.Three thousand nine hundred eighty-six patients were included in the study. Ninety-two (2%) patients required intensive care unit management, with a mean NEWS2 score of 7. A total of 158 patients died in hospital, of which 63 were women (40%). Of these 65 patients required intensive care unit management. The receiver operating characteristic curve for NEWS2 had an area of 0.90 (CI 95%: 0.87-0.92). A classification and score equivalency analysis was performed between triage and the NEWS2 scale in terms of mortality. Of the patients classified as triage I, 32.3% died, and those who obtained a NEWS2 score greater than or equal to 10 had a mortality of 38.6%.Among our population, NEWS2 was not inferior in its area under the receiver operating characteristic curve when predicting mortality than triage, and the cutoff point for NEWS2 to predict in-hospital mortality was higher.

Comparative Analysis Of Triage Systems At Emergency Departments Of Different Countries: Implementation In Kazakhstan

Medical sorting is aimed at assessment of disease severity and has to be carried out within a short time to determine the priorities for patient care and transportation to the most appropriate place for future treatment. The goal of this study was to provide an integrative review by analyzing the publications on the most common triage systems worldwide in order to select and implement the most reliable system at emergency departments. We searched for publications relevant to our comparative analysis in evidence-based medicine databases. A total of 1,740 literary sources were identified, of which 42 were selected for analysis. Comparative analysis of different triage systems may help implementing the most efficient system in Kazakhstan. The Emergency Severity Index is considered the most reliable and accurate tool used in international practice, and it could provide a basis for introduction of triage system at emergency departments in Kazakhstan.

Utility of the Emergency Severity Index by Accuracy of Interrater Agreement by Expert Triage Nurses in a Simulated Scenario in Japan: A Randomized Controlled Trial

OBJECTIVE

The Emergency Severity Index (ESI) is a highly reliable and valid triage scale that is widely used in emergency departments in not only English language regions but also other countries. The Japan Triage and Acuity Scale (JTAS) is frequently used for emergency patients, and the ESI has not been evaluated against the JTAS in Japan. This study aimed to examine the decision accuracy of the ESI for simulated clinical scenarios among nursing specialists in Japan compared with the JTAS.

METHOD

A parallel group randomized trial was conducted. In total, 23 JTAS-trained triage nurses from 10 Japanese emergency departments were randomly assigned to the ESI or the JTAS group. Nurses independently assigned triage categories to 80 emergency cases for the assessment of interrater agreement.

RESULTS

Interrater agreement between the expert and triage nurses was κ = 0.82 (excellent) in the ESI group and κ = 0.74 (substantial) in the JTAS group. In addition, interrater agreement by acuity was level 2 = 0.42 (moderate) in the ESI group and level 2 = 0.31 (fair) in the JTAS group. Interrater agreement for triage decisions was classified in a higher category in the ESI group than in the JTAS Scale group at level 2. Triage decisions based on the ESI in Japan maintained the same level of interrater agreement and sensitivity as those in other countries.

CONCLUSION

These findings suggest that the ESI can be introduced in Japan, despite its different emergency medical background compared with other countries.

Pediatric early warning score versus a paediatric triage tool in the emergency department: A reliability study

AIM

In the paediatric emergency department (PED), it is important to correctly prioritize children for physician assessment. The pediatric early warning score (PEWS), although not a triage tool, is often used for PED triage. The scandinavian Rapid Emergency Triage and Treatment System-pediatric (RETTS-p) is a reliability tested triage tool. We aimed to compare PEWS and RETTS-p in a Norwegian PED.

DESIGN

A reliability study.

METHODS

The PED nurse routinely did PEWS observations, while the principal investigator concomitantly made RETTS-p observations. Inter-tool agreement was calculated for the complete PEWS and RETTS-p and for vital signs scores, disregarding the RETTS-p emergency symptoms and signs (ESS).

RESULTS

Rapid Emergency Triage and Treatment System-pediatric assigned a higher urgency than PEWS. The inter-tool agreement between PEWS and RETTS-p was low (weighted kappa [95% confidence interval [CI] = 0.32 [0.24-0.40]]). Weighted kappa (95% CI) was 0.50 (0.41-0.59) for PEWS and RETTS-p without ESS, indicating that PEWS is not equivalent to five-level triage tools.

The HEAR-VA Pilot Study: Hearing Assistance Provided to Older Adults in the Emergency Department

BACKGROUND/OBJECTIVES

Poor communication is a barrier to care for people with hearing loss. We assessed the feasibility and potential benefit of providing a simple hearing assistance device during an emergency department (ED) visit, for people who reported difficulty hearing.

DESIGN

Randomized controlled pilot study.

SETTING

The ED of New York Harbor Manhattan Veterans Administration Medical Center.

PARTICIPANTS

One hundred and thirty-three Veterans aged 60 and older, presenting to the ED, likely to be discharged to home, who either (1) said that they had difficulty hearing, or (2) scored 10 or greater (range 0-40) on the Hearing Handicap Inventory-Survey (HHI-S).

INTERVENTION

Subjects were randomized (1:1), and intervention subjects received a personal amplifier (PA; Williams Sound Pocketalker 2.0) for use during their ED visit.

MEASUREMENTS

Three survey instruments: (1) six-item Hearing and Understanding Questionnaire (HUQ); (2) three-item Care Transitions Measure; and (3) three-item Patient Understanding of Discharge Information. Post-ED visit phone calls to assess ED returns.

RESULTS

Of the 133 subjects, 98.3% were male; mean age was 76.4 years (standard deviation (SD) = 9.2). Mean HHI-S score was 19.2 (SD = 8.3). Across all HUQ items, intervention subjects reported better in-ED experience than controls. Seventy-five percent of intervention subjects agreed or strongly agreed that ability to understand what was said was without effort versus 56% for controls. Seventy-five percent of intervention subjects versus 36% of controls said clinicians provided them with an explanation about presenting problems. Three percent of intervention subjects had an ED revisit within 3 days compared with 9.0% controls.

CONCLUSION

Veterans with hearing difficulties reported improved in-ED experiences with use of PAs, and were less likely to return to the ED within 3 days. PAs may be an important adjunct to older patient ED care but require validation in a larger more definitive randomized controlled trial.

Patterns and Predictors of Professional Interpreter Use in the Pediatric Emergency Department

BACKGROUND AND OBJECTIVES

Professional interpretation for patients with limited English proficiency remains underused. Understanding predictors of use is crucial for intervention. We sought to identify factors associated with professional interpreter use during pediatric emergency department (ED) visits.

METHODS

We video recorded ED visits for a subset of participants (n = 50; 20% of the total sample) in a randomized trial of telephone versus video interpretation for Spanish-speaking limited English proficiency families. Medical communication events were coded for duration, health professional type, interpreter (none, ad hoc, or professional), and content. With communication event as the unit of analysis, associations between professional interpreter use and assigned interpreter modality, health professional type, and communication content were assessed with multivariate random-effects logistic regression, clustered on the patient.

RESULTS

We analyzed 312 communication events from 50 ED visits (28 telephone arm, 22 video arm). Professional interpretation was used for 36% of communications overall, most often for detailed histories (89%) and least often for procedures (11%) and medication administrations (8%). Speaker type, communication content, and duration were all significantly associated with professional interpreter use. Assignment to video interpretation was associated with significantly increased use of professional interpretation for communication with providers (adjusted odds ratio 2.7; 95% confidence interval: 1.1-7.0).

CONCLUSIONS

Professional interpreter use was inconsistent over the course of an ED visit, even for patients enrolled in an interpretation study. Assignment to video rather than telephone interpretation led to greater use of professional interpretation among physicians and nurse practitioners but not nurses and other staff.

Dispatcher Triage Accuracy in the Western Cape Government Emergency Medical Services System, Cape Town, South Africa

INTRODUCTION

Triage - the sorting of patients according to urgency of need for clinical care - is an essential part of delivering effective and efficient emergency care. But when frequent over- or under-triaging occurs, finite time and resources are diverted away from those in greatest need of care and the entire Emergency Medical Services (EMS) system is strained. In resource-constrained settings, such as South Africa, poor triage in EMS only serves to compound other contextual challenges. This study examined the accuracy of dispatcher triage over a one-year period in the Western Cape Government (WCG) EMS system in South Africa.

METHODS

A retrospective analysis of existing dispatch and EMS data to assess the accuracy of dispatch-assigned priorities was conducted. The mismatch between dispatcher-assigned call priority and triage levels determined by EMS personnel was analyzed via over- and under-triage rates, sensitivity and specificity, and positive and negative predictive values (PPVs and NPVs, respectively).

RESULTS

A total of 185,166 records from December 2016 through November 2017 were analyzed. Across all dispatch complaints, the over-triage rate was 67.6% (95% CI, 66.34-68.76) and the under-triage rate was 16.2% (95% CI, 15.44-16.90). Dispatch triage sensitivity for all included records was 49.2% (95% CI, 48.10-50.38), specificity 71.9% (95% CI, 71.00-72.92), PPV 32.5% (95% CI, 30.02-34.88), and NPV 83.8% (95% CI, 81.93-85.73).

CONCLUSION

This study provides the first evaluation of dispatch triage accuracy in the WCG EMS system, identifying that the system is suffering from both under- and over-triage. Despite variance across dispatch complaints, both under- and over-triage remained higher than widely accepted norms, and all rates were significantly above acceptable target metrics described in similar studies. Results of this study will be used to motivate the development of more rigorous training programs and resources for WCG EMS dispatchers, including improved dispatch protocols for conditions suffering from high over- and under-triage.

A Method for Grouping Emergency Department Visits by Severity and Complexity

INTRODUCTION

Triage functions to quickly prioritize care and sort patients by anticipated resource needs. Despite widespread use of the Emergency Severity Index (ESI), there is still no universal standard for emergency department (ED) triage. Thus, it can be difficult to objectively assess national trends in ED acuity and resource requirements. We sought to derive an ESI from National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items (NHAMCS-ESI) and to assess the performance of this index with respect to stratifying outcomes, including hospital admission, waiting times, and ED length of stay (LOS).

METHODS

We used data from the 2010-2015 NHAMCS, to create a measure of ED visit complexity based on variables within NHAMCS. We used NHAMCS data on chief complaint, vitals, resources used, interventions, and pain level to group ED visits into five levels of acuity using a stepwise algorithm that mirrored ESI. In addition, we examined associations of NHAMCS-ESI with typical indicators of acuity such as waiting time, LOS, and disposition. The NHAMCS-ESI categorization was also compared against the "immediacy" variable across all of these outcomes. Visit counts used weighted scores to estimate national levels of ED visits.

RESULTS

The NHAMCS ED visits represent an estimated 805,726,000 ED visits over this time period. NHAMCS-ESI categorized visits somewhat evenly, with most visits (42.5%) categorized as a level 3. The categorization pattern is distinct from that of the "immediacy" variable within NHAMCS. Of admitted patients, 89% were categorized as NHAMCS-ESI level 2-3. Median ED waiting times increased as NHAMCS-ESI levels decreased in acuity (from approximately 14 minutes to 25 minutes). Median LOS decreased as NHAMCS-ESI decreased from almost 200 minutes for level 1 patients to nearly 80 minutes for level 5 patients.

CONCLUSION

We derived an objective tool to measure an ED visit's complexity and resource use. This tool can be validated and used to compare complexity of ED visits across hospitals and regions, and over time.

Explaining challenges of obstetric triage structure: A qualitative study

Aim

The purpose of this study was to explain the challenges of the obstetric triage structure.

Design

The present qualitative research was conducted with directed content analysis approach on 21 members of the triage team and the key informant using purposeful sampling in 2018.

Methods

The method of data collection was semi-structured interviews. Then, the accuracy and rigour of the qualitative data were examined.

Results

In this study, the most important challenges in the structure of obstetric triage were identified as pattern and standard, equipment, physical space, human resource and triage procedure and process. Correction and revision in the obstetric triage structure is important to provide high-quality services. Therefore, the quality of the structure can be developed and maintained accounting for the corresponding challenges.

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong

Background

Despite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, and over- and under-triage rates in real patient encounters in our setting.

Method

This was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the “criterion standard”), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patients requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics.

Results

In total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patients requiring earlier medical attention was as follows: sensitivity, 68.2% (95% CI 45.1–86.1%); specificity, 99.2% (95% CI 95.8–100%); positive predictive value, 93.8% (95% CI 67.6–99.1%); and negative predictive value, 94.8% (95% CI 90.8–97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60–0.92, p < 0.001), so was the agreement across nurses (quadratic-weighted kappa = 0.81, 95% CI 0.65–0.97, p < 0.001).

Conclusions

The 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.

The Association Between Patient Outcomes and the Initial Emergency Severity Index Triage Score in Patients With Suspected Acute Coronary Syndrome

BACKGROUND

The Emergency Severity Index (ESI) is a widely used tool to triage patients in emergency departments. The ESI tool is used to assess all complaints and has significant limitation for accurately triaging patients with suspected acute coronary syndrome (ACS).

OBJECTIVE

We evaluated the accuracy of ESI in predicting serious outcomes in suspected ACS and aimed to assess the incremental reclassification performance if ESI is supplemented with a clinically validated tool used to risk-stratify suspected ACS.

METHODS

We used existing data from an observational cohort study of patients with chest pain. We extracted ESI scores documented by triage nurses during routine medical care. Two independent reviewers adjudicated the primary outcome, incidence of 30-day major adverse cardiac events. We compared ESI with the well-established modified HEAR/T (patient History, Electrocardiogram, Age, Risk factors, but without Troponin) score.

RESULTS

Our sample included 750 patients (age, 59 ± 17 years; 43% female; 40% black). A total of 145 patients (19%) experienced major adverse cardiac event. The area under the receiver operating characteristic curve for ESI score for predicting major adverse cardiac event was 0.656, compared with 0.796 for the modified HEAR/T score. Using the modified HEAR/T score, 181 of the 391 false positives (46%) and 16 of the 19 false negatives (84%) assigned by ESI could be reclassified correctly.

CONCLUSION

The ESI score is poorly associated with serious outcomes in patients with suspected ACS. Supplementing the ESI tool with input from other validated clinical tools can greatly improve the accuracy of triage in patients with suspected ACS.

Validity and Reliability of the Emergency Severity Index in a Spanish Hospital

Saturation in hospital emergency departments is one of the main safety problems for the patient, which can generate negative consequences for their health. In response to this issue, triage systems are developed to organize the flow of patients in order to allow the most urgent ones to be treated first. The Emergency Severity Index (ESI) is the most used triage system in the USA and it has been implemented in the General Hospital of La Palma since 2010. The objective of this study is the validation of the ESI adapted to our hospital through the study of its degree of reliability, as well as the criterion validity. The sample consisted of 240 randomly selected cases, with proportional representation of emergencies attended in 2015 and their fraction of urgent ones (Levels 1 and 2). Criterion validity was estimated by sensitivity, specificity, and predictive result values. For reliability, the degree of agreement among the nurses was studied by means of the adapted kappa index k_c2. Criterion validity showed a sensitivity of 89% (85-93%) and a specificity of 97% (94-99%), with a positive predictive value of 68% (62-74%) and a negative predictive value of 99% (98-100%) for the discrimination of urgent cases. The reliability analysis showed a k_c2 = 0.94 (0.84-0.99) index, a very good agreement according to Landis-Koch criteria. The results of our study have shown adequate validity and reliability in the adaptation and implementation of an ESI triage system suited to the specific conditions of a hospital emergency service in Spain.

Effectiveness of Implementing Emergency Severity Index Triage System in a Selected Primary Health Care Center in Oman: A Quasi-Experimental Study

BACKGROUND

Because most primary health care centers in Oman do not use a formal triage system, there are no available data on the effectiveness of implementing this system.

PURPOSE

To assess the effectiveness of implementing an Emergency Severity Index triage system in primary health care centers in Oman.

METHODS

A pretest/posttest quasi-experimental design was used. The sample comprised 187 patients before Emergency Severity Index implementation and 102 patients after implementation. Waiting time, length of stay, patient satisfaction, and accuracy of classification were compared across the 2 groups.

RESULTS

The mean time (hour:minute) from registration to triage was reduced in the post-Emergency Severity Index group (mean = 0:18, SD = 0:14) compared with the pre-Emergency Severity Index group (mean = 0:23, SD = 0:19) (t = 2.59, P = 0.01). Furthermore, the mean length of stay was reduced in the post-Emergency Severity Index group (mean = 1:09, SD = 0:37) compared with that of the preimplementation group (mean = 1:24, SD = 0:41) (t = 3.10, P = 0.002). Patient satisfaction in the postimplementation group was improved (mean = 66.95, SD = 8.33) compared with that of the Emergency Severity Index group (mean = 65.01, SD = 8.73), but it did not reach statistical significance (t = -1.83, P = 0.07). The inter-rater agreement of triage level in post-Emergency Severity Index implementation markedly improved in the postimplementation group (Cohen's kappa = 0.910, P < 0.001) compared with that of the preimplementation group (Cohen's kappa = 0.082, P = 0.005).

CONCLUSIONS

Although this is a single-setting study, the results have shown that the Emergency Severity Index system can contribute to a decrease in the negative crowding outcomes in primary health care centers in Oman.

The Quality of the Maternity Triage Process: a Qualitative Study

Introduction:

There is no consensus on what the bases and criteria are for the dynamic process of maternity triage. Properly performing the maternity triage process requires reliable data to ensure the correct implementation of this process and the identification of existing deficiencies, and find strategies to modify, improve and enhance the quality of this process.

Objective:

The present study was conducted to explain the quality of the maternity triage process.

Methods:

The present qualitative study performed a directed content analysis on 19 maternity triage service providers and key informants selected through purposive sampling. The data were collected through semi-structured interviews in 2018 and analyzed using directed content analysis based on the Donabedian’s model. The accuracy and rigor of the qualitative data were then investigated and confirmed.

Results:

The participants identified the most important factors affecting the quality of the services provided in maternity triage as two categories of measures and care, and interactions and communication. The category of measures and care included two subcategories of examinations and obtaining a medical history.

Conclusion:

The present study comprehensively identified different dimensions of the quality of maternity triage services at different levels. The participants identified the quality of the maternity triage process as a multi-dimensional and important concept. Different dimensions of the maternity triage process are recommended that be addressed when designing and implementing maternity triage guidelines and instructions so as to maintain the quality of this process and satisfy their needs.

Resident Clinical Experience in the Emergency Department: Patient Encounters by Postgraduate Year

BACKGROUND

During emergency medicine (EM) training, residents are exposed to a wide spectrum of patient complaints. We sought to determine how resident clinical experience changes based on training level in relation to the patient acuity levels, chief complaints, and dispositions.

METHODS

We performed a retrospective chart review of patients seen at a safety-net, academic hospital in Los Angeles from July 1, 2015, to June 30, 2016. Resident postgraduate year (PGY) level and specialty, patient acuity (based on the Emergency Severity Index), chief complaint (based on one of 30 categories), and disposition were abstracted. Our primary objective was to examine the progression of EM resident experience throughout the course of training. As a secondary objective, we compared the cases seen by EM and off-service PGY-1s.

RESULTS

A total of 49,535 visits were examined, and of these, 32,870 (66.4%) were in the adult ED (AED) and 16,665 (33.6%) were in the pediatric ED (PED). The median acuity level was 3, and 27.4% of AED patients and 7.3% of PED patients were admitted. Data from 126 residents were analyzed. This included 94 PGY-1 residents (16 EM and 78 off-service), 16 PGY-2 EM, and 16 PGY-3 EM residents. Residents of different training levels evaluated different types of patients. Senior EM residents were more likely to care for higher-acuity patients than junior EM residents. EM PGY-3s saw higher percentages of acuity level 1 and 2 patients (2.3 and 37.8%, respectively, of their total patients) than EM PGY-1s (0.3 and 18.7%, respectively). Conversely, EM PGY-1s saw higher percentages of acuity level 4 and 5 patients (27.9 and 1.6%, respectively) compared to EM PGY-3s (10.7 and 0.7%, respectively). There was a significant linear trend for increasing acuity with training year among EM residents (p < 0.001). EM PGY-1s saw more patients than off-service PGY-1s with slightly higher acuities and admission rates.

CONCLUSION

The clinical experience of EM residents varies based on their level of training. EM residents show a progression throughout residency and are more likely to encounter higher volumes of patients with higher acuity as they progress in their training. When designing EM residency curriculums, this is a model of an EM residency program.

Triage Systems in Mass Casualty Incidents and Disasters: A Review Study with A Worldwide Approach

BACKGROUND:

Injuries caused by emergencies and accidents are increasing in the world. To prioritise patients to provide them with proper services and to optimally use the resources and facilities of the medical centres during accidents, the use of triage systems, which are one of the key principles of accident management, seems essential.

AIM:

This study is an attempt to identify available triage systems and compare the differences and similarities of the standards of these systems during emergencies and disasters through a review study.

METHODS:

This study was conducted through a review of the triage systems used in emergencies and disasters throughout the world. Accordingly, all articles published between 1990 and 2018 in both English and Persian journals were searched based on several keywords including Triage, Disaster, Mass Casualty Incidents, in the Medlib, Scopus, Web of Science, PubMed, Cochrane Library, Science Direct, Google scholar, Irandoc, Magiran, Iranmedex, and SID databases in isolation and in combination using both and/ or conjunctions.

RESULTS:

Based on the search done in these databases, twenty different systems were identified in the primary adult triage field including START, Homebush triage Standard, Sieve, CareFlight, STM, Military, CESIRA Protocol, MASS, Revers, CBRN Triage, Burn Triage, META Triage, Mass Gathering Triage, SwiFT Triage, MPTT, TEWS Triage, Medical Triage, SALT, mSTART and ASAV. There were two primary triage systems including Jump START and PTT for children, and also two secondary triage systems encompassing SAVE and Sort identified in this respect. ESI and CRAMS were two other cases distinguished for hospital triage systems.

CONCLUSION:

There are divergent triage systems in the world, but there is no general and universal agreement on how patients and injured people should be triaged. Accordingly, these systems may be designed based on such criteria as vital signs, patient’s major problems, or the resources and facilities needed to respond to patients’ needs. To date, no triage system has been known as superior, specifically about the patients’ clinical outcomes, improvement of the scene management or allocation of the resources compared to other systems. Thus, it is recommended that different countries such as Iran design their triage model for emergencies and disasters by their native conditions, resources and relief forces.

Delayed Recognition of Acute Stroke by Emergency Department Staff Following Failure to Activate Stroke by Emergency Medical Services

Introduction

Early recognition and pre-notification by emergency medical services (EMS) improves the timeliness of emergency department (ED) stroke care; however, little is known regarding the effects on care should EMS providers fail to pre-notify. We sought to determine if potential stroke patients transported by EMS, but for whom EMS did not provide pre-notification, suffer delays in ED door-to-stroke-team activation (DTA) as compared to the other available cohort of patients for whom the ED is not pre-notified–those arriving by private vehicle.

Methods

We queried our prospective stroke registry to identify consecutive stroke team activation patients over 12 months and retrospectively reviewed the electronic health record for each patient to validate registry data and abstract other clinical and operational data. We compared patients arriving by private vehicle to those arriving by EMS without pre-notification, and we employed a multivariable, penalized regression model to assess the probability of meeting the national DTA goal of ≤15 minutes, controlling for a variety of clinical factors.

Results

Our inclusion criteria were met by 200 patients. Overall performance of the regression model was excellent (area under the curve 0.929). Arrival via EMS without pre-notification, compared to arrival by private vehicle, was associated with an adjusted risk ratio of 0.55 (95% confidence interval, 0.27–0.96) for achieving DTA ≤ 15 minutes.

Conclusion

Our single-center data demonstrate that potential stroke patients arriving via EMS without pre-notification are less likely to meet the national DTA goal than patients arriving via other means. These data suggest a negative, unintended consequence of otherwise highly successful EMS efforts to improve stroke care, the root of which may be ED staff over-reliance on EMS for stroke recognition.

Triage Performance in Emergency Medicine: A Systematic Review

STUDY OBJECTIVE

Rapid growth in emergency department (ED) triage literature has been accompanied by diversity in study design, methodology, and outcome assessment. We aim to synthesize existing ED triage literature by using a framework that enables performance comparisons and benchmarking across triage systems, with respect to clinical outcomes and reliability.

METHODS

PubMed, EMBASE, Scopus, and Web of Science were systematically searched for studies of adult ED triage systems through 2016. Studies evaluating triage systems with evidence of widespread adoption (Australian Triage Scale, Canadian Triage and Acuity Scale, Emergency Severity Index, Manchester Triage Scale, and South African Triage Scale) were cataloged and compared for performance in identifying patients at risk for mortality, critical illness and hospitalization, and interrater reliability. This study was performed and reported in adherence to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines.

RESULTS

A total of 6,160 publications were identified, with 182 meeting eligibility criteria and 50 with sufficient data for inclusion in comparative analysis. The Canadian Triage and Acuity Scale (32 studies), Emergency Severity Index (43), and Manchester Triage Scale (38) were the most frequently studied triage scales, and all demonstrated similar performance. Most studies (6 of 8) reported high sensitivity (>90%) of triage scales for identifying patients with ED mortality as high acuity at triage. However, sensitivity was low (<80%) for identification of patients who had critical illness outcomes and those who died within days of the ED visit or during the index hospitalization. Sensitivity varied by critical illness and was lower for severe sepsis (36% to 74%), pulmonary embolism (54%), and non-ST-segment elevation myocardial infarction (44% to 85%) compared with ST-segment elevation myocardial infarction (56% to 92%) and general outcomes of ICU admission (58% to 100%) and lifesaving intervention (77% to 98%). Some proportion of hospitalized patients (3% to 45%) were triaged to low acuity (level 4 to 5) in all studies. Reliability measures (κ) were variable across evaluations, with only a minority (11 of 42) reporting κ above 0.8.

CONCLUSION

We found that a substantial proportion of ED patients who die postencounter or are critically ill are not designated as high acuity at triage. Opportunity to improve interrater reliability and triage performance in identifying patients at risk of adverse outcome exists.

Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review

OBJECTIVE

Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs.

METHODS

We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria.

RESULTS

Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence.

CONCLUSION

The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.

Emergency Medical Services Utilization Is Associated With Community Deprivation in Children

BACKGROUND

Pediatric emergency medical services (EMS) utilization is costly and resource intensive; significant variation exists across large-scale geographies. Less is known about variation at smaller geographic levels where factors including lack of transportation, low health literacy, and decreased access to medical homes may be more relevant. Our objective was to determine whether pediatric EMS utilization varied across Hamilton County, Ohio, census tracts and whether such utilization was associated with socioeconomic deprivation.

METHODS

This was a retrospective analysis of children living in Hamilton County, Ohio, transported by EMS to the Cincinnati Children's emergency department between July 1, 2014, and July 31, 2016. Participants' addresses were assigned to census tracts and an EMS utilization rate and deprivation index were calculated for each. Pearson's correlation coefficients evaluated relationships between tract-level EMS utilization and deprivation. Tract-level deprivation was used as a predictor in patient-level evaluations of acuity.

RESULTS

During the study period, there were 4,877 pediatric EMS transports from 219 of the 222 county census tracts. The county EMS utilization rate during the study period was 2.4 transports per 100 children (range 0.2-11). EMS utilization rates were positively correlated with increasing deprivation (r = 0.72, 95% confidence interval [CI], 0.65-0.77). Deprivation was associated with lower illness severity at triage, fewer transports resulting in resuscitation suite use, and fewer transports resulting in hospitalizations (all p < 0.05).

CONCLUSIONS

EMS utilization varied substantially across census tracts in Hamilton County, Ohio. A deeper understanding into why certain socioeconomically deprived areas contribute to disproportionately high rates of EMS utilization could support development of targeted interventions to improve use.

Mobile Decision Support Tool for Emergency Departments and Mass Casualty Incidents (EDIT): Initial Study

Background

Chemical exposures pose a significant threat to life. A rapid assessment by first responders and emergency nurses is required to reduce death and disability. Currently, no informatics tools exist to process victims of chemical exposures efficiently. The surge of patients into a hospital emergency department during a mass casualty incident creates additional stress on an already overburdened system, potentially placing patients at risk and challenging staff to process patients for appropriate care and treatment efficacy. Traditional emergency department triage models are oversimplified during highly stressed mass casualty incident scenarios in which there is little margin for error. Emerging mobile technology could alleviate the burden placed on nurses by allowing the freedom to move about the emergency department and stay connected to a decision support system.

Objective

This study aims to present and evaluate a new mobile tool for assisting emergency department personnel in patient management and triage during a chemical mass casualty incident.

Methods

Over 500 volunteer nurses, students, and first responders were recruited for a study involving a simulated chemical mass casualty incident. During the exercise, a mobile application was used to collect patient data through a kiosk system. Nurses also received tablets where they could review patient information and choose recommendations from a decision support system. Data collected was analyzed on the efficiency of the app to obtain patient data and on nurse agreement with the decision support system.

Results

Of the 296 participants, 96.3% (288/296) of the patients completed the kiosk system with an average time of 3 minutes, 22 seconds. Average time to complete the entire triage process was 5 minutes, 34 seconds. Analysis of the data also showed strong agreement among nurses regarding the app’s decision support system. Overall, nurses agreed with the system 91.6% (262/286) of the time when it came to choose an exposure level and 84.3% (241/286) of the time when selecting an action.

Conclusions

The app reliably demonstrated the ability to collect patient data through a self-service kiosk system thus reducing the burden on hospital resources. Also, the mobile technology allowed nurses the freedom to triage patients on the go while staying connected to a decision support system in which they felt would give reliable recommendations.

Contributions of Academic Emergency Medicine Programs to U.S. Health Care: Summary of the AAAEM-AACEM Benchmarking Data

OBJECTIVES

The societal contribution of emergency care in the United States has been described. The role and impact of academic emergency departments (EDs) has been less clear. Our report summarizes the results of a benchmarking effort specifically focused on academic emergency medicine (EM) practices.

METHODS

From October through December 2016, the Academy of Academic Administrators of Emergency Medicine (AAAEM) and the Association of Academic Chairs of Emergency Medicine (AACEM) jointly administered a benchmarking survey to allopathic, academic departments and divisions of emergency medicine. Participation was voluntary and nonanonymous. The survey queried various aspects of the three components of the tripartite academic mission: clinical care, education and research, and faculty effort and compensation. Responses reflected a calendar year from July 1, 2015, to June 30, 2016.

RESULTS

Of 107 eligible U.S. allopathic, academic departments and divisions of emergency medicine, 79 (74%) responded to the survey overall, although individual questions were not always answered by all responding programs. The 79 responding programs reported 6,876,189 patient visits at 97 primary and affiliated academic clinical sites. A number of clinical operations metrics related to the care of these patients at these sites are reported in this study. All responding programs had active educational programs for EM residents, with a median of 37 residents per program. Nearly half of the overall respondents reported responsibility for teaching medical students in mandatory EM clerkships. Fifty-two programs reported research and publication activity, with a total of $129,494,676 of grant funding and 3,059 publications. Median faculty effort distribution was clinical effort, 66.9%; education effort, 12.7%; administrative effort, 12.0%; and research effort, 6.9%. Median faculty salary was $277,045.

CONCLUSIONS

Academic EM programs are characterized by significant productivity in clinical operations, education, and research. The survey results reported in this investigation provide appropriate benchmarking for academic EM programs because they allow for comparison of academic programs to each other, rather than nonacademic programs that do not necessarily share the additional missions of research and education and may have dissimilar working environments.

Do Patients with Chest Pain Benefit from Installing Triage System in Emergency Department?

INTRODUCTION

Chest pain, which can be cardiac or non-cardiac and either benign or life-threatening, needs appropriate diagnosis and treatment in emergency department (ED).

OBJECTIVE

The aim of this study was to compare delivery time of primary care for patients with chest pain before and after applying triage system in ED.

METHODS

Medical records were reviewed of thirty patients (group one) with chief complaint of chest pain who referred to ED between April and July 2008 (before installing triage system) and thirty-five patients (group two) with the same chief complaint who referred between August and September 2009 (after installing triage system). Time between patients' arrival and beginning of diagnostic and therapeutic interventions including cardiac monitoring, first physician visit time, intravenous line insertion, and electrocardiogram performance were compared between the two groups.

RESULTS

Based on the findings, the mean age and sex ratio of studied patients in the two groups were not significantly different (p>0.05). Door to ECG performance, Door to intravenous line insertion, and Door to cardiac monitoring were significantly shorter in post triage installing period than previously (p<0.001). Door to first visit by physician was not statistically different in the two study periods (p=0.421).

CONCLUSION

It is likely that patients with chest pain who referred to ED benefit from installing triage system in terms of performing some nursing care including ECG performance, starting cardiac monitoring, and IV insertion.

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

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

Simulation-Based Design of ED Operations with Care Streams to Optimize Care Delivery and Reduce Length of Stay in the Emergency Department

Faced with the opportunity to significantly deviate from classic operations, a new emergency department (ED) and novel strategy for patient care delivery were simultaneously initiated with the aid of model-based simulation. To answer the design and implementation questions, a traditional strategy for construction of discrete-eventmodel simulation was employed to define ED operations for a newly constructed facility in terms of workflow, variables, resources, structure, process logic and associated assumptions. Benefits were achieved before, during and after implementation of an unprecedented operations strategy-i.e., the organization of the ED care delivery around four care streams: Critical, Diagnostic, Therapeutic and Fast Track. Prior to opening, it shed light on the range of context variables where benefits might be anticipated, and it facilitated staff understanding and judgements of performance. Two years after opening, the operations data is compared to the simulation with encouraging results that shed light on where to continue pursuit of improvement.

Five-level emergency triage systems: variation in assessment of validity

INTRODUCTION

Triage systems are scales developed to rate the degree of urgency among patients who arrive at EDs. A number of different scales are in use; however, the way in which they have been validated is inconsistent. Also, it is difficult to define a surrogate that accurately predicts urgency. This systematic review described reference standards and measures used in previous validation studies of five-level triage systems.

METHODS

We searched PubMed, EMBASE and CINAHL to identify studies that had assessed the validity of five-level triage systems and described the reference standards and measures applied in these studies. Studies were divided into those using criterion validity (reference standards developed by expert panels or triage systems already in use) and those using construct validity (prognosis, costs and resource use).

RESULTS

A total of 57 studies examined criterion and construct validity of 14 five-level triage systems. Criterion validity was examined by evaluating (1) agreement between the assigned degree of urgency with objective standard criteria (12 studies), (2) overtriage and undertriage (9 studies) and (3) sensitivity and specificity of triage systems (7 studies). Construct validity was examined by looking at (4) the associations between the assigned degree of urgency and measures gauged in EDs (48 studies) and (5) the associations between the assigned degree of urgency and measures gauged after hospitalisation (13 studies). Particularly, among 46 validation studies of the most commonly used triages (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System), 13 and 39 studies examined criterion and construct validity, respectively.

CONCLUSION

Previous studies applied various reference standards and measures to validate five-level triage systems. They either created their own reference standard or used a combination of severity/resource measures.

Is the South African Triage Scale valid for use in Afghanistan, Haiti and Sierra Leone?

Objective

To assess the validity of the South African Triage Scale (SATS) in four Médecins Sans Frontières (MSF)-supported emergency departments (ED, two trauma-only sites, one mixed site (both medical and trauma cases) and one paediatric-only site) in Afghanistan, Haiti and Sierra Leone.

Methods

This was a retrospective cohort study conducted between June 2013 and June 2014. Validity was assessed by comparing patients’ SATS ratings with their final ED outcome (ie, hospital admission, death or discharge).

Results

In the two trauma settings, the SATS demonstrated good validity: it accurately predicted an increase in the likelihood of mortality and hospitalisation across incremental acuity levels (p<0.001) and ED outcomes for ‘green’ and ‘red’ patients matched the predicted ED outcomes in 84%–99% of cases. In the mixed ED, the SATS was able to predict an incremental increase in hospitalisation (p<0.001) across both trauma and non-trauma cases. In the paediatric-only settings, SATS was able to predict an incremental increase in hospitalisation in the non-trauma cases only (p<0.001). However, 87% (non-trauma) and 94% (trauma) of ‘red’ patients in the mixed-medical setting were overtriaged and 76% (non-trauma) and 100% (trauma) of ‘green’ patients in the paediatric settings were undertriaged.

Conclusion

The SATS is a valid tool for trauma-only settings in low-resource countries. Its use in mixed settings seems justified, but context-specific assessments would seem prudent. Finally, in paediatric settings with endemic malaria, adding haemoglobin level to the SATS discriminator list may help to improve the undertriage of patients with malaria.

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

Background

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

Objective

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

Method

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

Result

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

Conclusion

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

Door-to-Imaging Time for Acute Stroke Patients Is Adversely Affected by Emergency Department Crowding

Background and Purpose—

National guidelines call for door-to-imaging time (DIT) within 25 minutes for suspected acute stroke patients. Studies examining factors that affect DIT have focused primarily on stroke-specific care processes and patient-specific factors. We hypothesized that emergency department (ED) crowding is associated with longer DIT.

Methods—

We conducted a retrospective investigation of 1 year of consecutive patients in our prospective Code Stroke registry, which included all ED stroke team activations. The registry and electronic health records were abstracted for 27 potential predictors of DIT, including patient, stroke care process, and ED operational factors. We fit a multivariate logistic regression model and calculated odds ratios and 95% confidence intervals. Second, we constructed a random forest recursive partitioning model to cross-validate our findings and explore the proportional importance of each category of predictor. Our primary outcome was the binary variable of DIT within the 25-minute goal.

Results—

A total of 463 patients met inclusion criteria. In the regression model, ED occupancy rate emerged as a predictor of DIT, with odds ratio of 0.83 (95% confidence interval, 0.75–0.91) of DIT within 25 minutes per 10% absolute increase in ED occupancy rate. The secondary analysis estimated that ED operational factors accounted for nearly 14% of the algorithm’s prediction of DIT.

Conclusions—

ED crowding is associated with reduced odds of meeting DIT goals for acute stroke. In addition to improving stroke-specific processes of care, efforts to reduce ED overcrowding should be considered central to optimizing the timeliness of acute stroke care.

One-two-triage: validation and reliability of a novel triage system for low-resource settings

Objectives

To validate and assess reliability of a novel triage system, one-two-triage (OTT), that can be applied by inexperienced providers in low-resource settings.

Methods

This study was a two-phase prospective, comparative study conducted at three hospitals. Phase I assessed criterion validity of OTT on all patients arriving at an American university hospital by comparing agreement among three methods of triage: OTT, Emergency Severity Index (ESI) and physician-defined acuity (the gold standard). Agreement was reported in normalised and raw-weighted Cohen κ using two different scales for weighting, Expert-weighted and triage-weighted κ. Phase II tested reliability, reported in Fleiss κ, of OTT using standardised cases among three groups of providers at an urban and rural Cambodian hospital and the American university hospital.

Results

Normalised for prevalence of patients in each category, OTT and ESI performed similarly well for expert-weighted κ (OTT κ=0.58, 95% CI 0.52 to 0.65; ESI κ=0.47, 95% CI 0.40 to 0.53) and triage-weighted κ (κ=0.54, 95% CI 0.48 to 0.61; ESI κ=0.57, 95% CI 0.51 to 0.64). Without normalising, agreement with gold standard was less for both systems but performance of OTT and ESI remained similar, expert-weighted (OTT κ=0.57, 95% CI 0.52 to 0.62; ESI κ=0.6, 95% CI 0.58 to 0.66) and triage-weighted (OTT κ=0.31, 95% CI 0.25 to 0.38; ESI κ=0.41, 95% CI 0.35 to 0.4). In the reliability phase, all triagers showed fair inter-rater agreement, Fleiss κ (κ=0.308).

Conclusions

OTT can be reliably applied and performs as well as ESI compared with gold standard, but requires fewer resources and less experience.