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Zhang W, Zhang M, Yang P, Zhou W, Zheng J, Zhang Y. The reliability and validity of triage tools in geriatric emergency departments: A scoping review. Int Emerg Nurs 2024; 77:101509. [PMID: 39288468 DOI: 10.1016/j.ienj.2024.101509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 08/13/2024] [Accepted: 08/24/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND The nurse's ability to accurately identify urgent conditions and triage this vulnerable population tends to be complex and challenging. Little is known about the reliability and validity of common triage tools in geriatric patients. AIM To determine the reliability and validity of triage tools in geriatric emergency care and summarize the specific content of current triage tools for geriatric patients. METHODS The eligible literature was searched from the MEDLINE, CINAHL, EMBASE, and Cochrane Database using targeted search strategies. We defined the objectives and questions, set standards for article inclusion criteria, and conducted literature searching and screening. The mixed methods assessment tool (MMAT) appraised the article's quality. Finally, we extracted and analyzed the data from the included articles, summarizing the results. Endnote X9 was used for data extraction and collation. RESULTS Nine articles were eligible. These included six triage tools: CTAS, JTAS, KTAS, MTS, SETS, and ESI. The reliability of the CTAS was good when applied to triage geriatric patients. The SETS performed well in prehospital simulated triage. The ESI has moderate to excellent reliability. The CTAS has good to excellent validity, while the JTAS, KTAS, MTS, and ESI have fair to good results. CONCLUSION Several triage tools are useful in geriatrics, but the reliability and validity of these tools have mixed results. Applying triage tools to triage geriatric patients still has limitations.
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Affiliation(s)
- Wenhui Zhang
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Mengxia Zhang
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Piaoyu Yang
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Wanting Zhou
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jili Zheng
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai, China.
| | - Yuxia Zhang
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China.
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2
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Zaboli A, Brigo F, Cipriano A, Sibilio S, Magnarelli G, Pfeifer N, Fratti M, Malalan F, Massar M, Mian M, Pagnucci N, Brigiari G, Ghiadoni L, Turcato G. Assessing triage efficiency in Italy: a comparative study using simulated cases among nurses. Intern Emerg Med 2024:10.1007/s11739-024-03735-z. [PMID: 39105967 DOI: 10.1007/s11739-024-03735-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Accepted: 07/31/2024] [Indexed: 08/07/2024]
Abstract
BACKGROUND Emergency Departments (EDs) across Italy use different triage systems, which vary from region to region. This study aimed to assess whether nurses working in different EDs assign triage codes in a similar and standardized manner. METHODS A multicenter observational simulation study involved the EDs of Bolzano Hospital, Merano Hospital, Pisa University Hospital, and Rovereto Hospital. All participating nurses were given 30 simulated clinical cases (vignettes) and asked to assign triage codes according to the triage systems used in their EDs. Subsequently, we assessed inter-rater agreement and evaluated if code assignment had different performance among hospitals in relation to different clinical outcomes. RESULTS Eighty-seven nurses participated in this study. There was marked variation in assigned triage codes both across hospitals and among individual operators. The kappa values for inter-rater agreement were 0.632 for Bolzano Hospital, 0.589 for Merano Hospital, 0.464 for Pisa University Hospital, and 0.574 for Rovereto Hospital. Sensitivity and specificity levels varied considerably for the same outcomes when comparing different hospitals. CONCLUSION There is a high degree of subjectivity in triage code assignment by ED nurses. In the interest of equitable care for patients, this variability within the same country is hardly acceptable.
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Affiliation(s)
- Arian Zaboli
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), via A. Volta, 13°, Bolzano, Italy.
| | - Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), via A. Volta, 13°, Bolzano, Italy
| | - Alessandro Cipriano
- Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Serena Sibilio
- Department Public Health, Institute of Nursing Science, Universitat Basel, Basel, BS, Switzerland
| | - Gabriele Magnarelli
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria
| | - Norbert Pfeifer
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy
- Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria
| | - Michele Fratti
- Emergency Department, S. Maria del Carmine Hospital, Azienda per i Servizi Sanitari di Trento, Rovereto, Italy
| | - Fabio Malalan
- Emergency Department, S. Maria del Carmine Hospital, Azienda per i Servizi Sanitari di Trento, Rovereto, Italy
| | - Magdalena Massar
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), via A. Volta, 13°, Bolzano, Italy
| | - Michael Mian
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), via A. Volta, 13°, Bolzano, Italy
- College of Health Care-Professions Claudiana, Bozen, Italy
| | - Nicola Pagnucci
- Department of Translational Research and of New Surgical and Medical Technologies University of Pisa, Pisa, Italy
| | - Gloria Brigiari
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - Lorenzo Ghiadoni
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gianni Turcato
- Intermediate Care Unit, Department of Internal Medicine, Hospital Alto Vicentino (AULSS-7), Santorso, Italy
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Zaboli A, Sibilio S, Massar M, Brigiari G, Magnarelli G, Parodi M, Mian M, Pfeifer N, Brigo F, Turcato G. Enhancing triage accuracy: The influence of nursing education on risk prediction. Int Emerg Nurs 2024; 75:101486. [PMID: 38936274 DOI: 10.1016/j.ienj.2024.101486] [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: 04/07/2024] [Revised: 05/29/2024] [Accepted: 06/12/2024] [Indexed: 06/29/2024]
Abstract
AIM This study aimed to compare the performance in risk prediction of various outcomes between specially trained triage nurses and the Manchester Triage System (MTS). DESIGN Prospective observational study. METHODS The study was conducted from June 1st to December 31st, 2023, at the Emergency Department of Merano Hospital. Triage nurses underwent continuous training through dedicated courses and daily audits. We compared the risk stratification performed by expert nurses with that of MTS on various outcomes such as mortality, hospitalisation, and urgency defined by the physicians. Comparisons were made using the Areas Under the Receiver Operating Characteristic curve (AUROC). RESULTS The agreement in code classification between the MTS and the expert nurse was very low. The AUROC curve analysis showed that the expert nurse outperformed the MTS in all outcomes. The triage nurse's experience led to statistically significant better stratification in admission rates, ICU admissions, and all outcomes based on the physician's assessment. CONCLUSIONS The continuous training of nurses enables them to achieve better risk prediction compared to standardized triage systems like MTS, emphasizing the utility and necessity of implementing continuous training pathways for these highly specialised personnel.
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Affiliation(s)
- Arian Zaboli
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy.
| | - Serena Sibilio
- Universitat Basel, Department Public Health, Institute of Nursing Science, Basel, BS, Switzerland
| | - Magdalena Massar
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy
| | - Gloria Brigiari
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Gabriele Magnarelli
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy; Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria
| | - Marta Parodi
- Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), Santorso, Italy
| | - Michael Mian
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy; College of Health Care-Professions Claudiana, Bozen, Italy
| | - Norbert Pfeifer
- Department of Emergency Medicine, Hospital of Merano-Meran (SABES-ASDAA), Merano-Meran, Italy; Lehrkrankenhaus der Paracelsus Medizinischen Privatuniversität, Salzburg, Austria
| | - Francesco Brigo
- Innovation, Research and Teaching Service (SABES-ASDAA), Teaching Hospital of the Paracelsus Medical Private University (PMU), Bolzano, Italy
| | - Gianni Turcato
- Department of Internal Medicine, Intermediate Care Unit, Hospital Alto Vicentino (AULSS-7), Santorso, Italy
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Wolf L, Russell A. The Relationship Between Accurate Triage and Core Measures Compliance for Acute Myocardial Infarction and Heart Failure in Older Adults Presenting to the Emergency Department. J Nurs Care Qual 2024; 39:183-187. [PMID: 37782846 DOI: 10.1097/ncq.0000000000000746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
BACKGROUND Accurate emergency department (ED) triage in the geriatric population is an important nurse-sensitive quality indicator; however, few quality indicators are verified for impact. PURPOSE To examine the relationship between triage accuracy in adults older than 65 years and Core Measures for acute myocardial infarction (AMI) and heart failure (HF). METHODS A correlational approach was used to determine strength and direction of the relationship between variables. RESULTS Strong positive correlations were found between triage accuracy and mortality for AMI and HF, as well as with 30-day hospital readmissions for AMI. A weak negative correlation was found between triage accuracy and 30-day hospital readmissions for HF. CONCLUSIONS Accurate triage can lead to a more effective care trajectory for patients, better adherence to Core Measures, and better outcomes. Accuracy in triage for AMI and HF is a valid indicator of ED quality care.
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Affiliation(s)
- Lisa Wolf
- Emergency Nursing Research, Emergency Nurses Association, Schaumburg, Illinois (Dr Wolf); and Mednition, Inc, San Mateo, California (Ms Russell)
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5
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Kemps N, Holband N, Boeddha NP, Faal A, Juliana AE, Kavishe GA, Keitel K, van ‘t Kruys KH, Ledger EV, Moll HA, Prentice AM, Secka F, Tan R, Usuf E, Unger SA, Zachariasse JM. Validation of the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in low- and middle-income countries: A multicentre observational study. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002716. [PMID: 38512949 PMCID: PMC10956749 DOI: 10.1371/journal.pgph.0002716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 02/22/2024] [Indexed: 03/23/2024]
Abstract
Early recognition of children at risk of serious illness is essential in preventing morbidity and mortality, particularly in low- and middle-income countries (LMICs). This study aimed to validate the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in acute care settings in LMICs. This observational study is based on previously collected clinical data from consecutive children attending four diverse settings in LMICs. Inclusion criteria and study periods (2010-2021) varied. We simulated the ED-PEWS, consisting of patient age, consciousness, work of breathing, respiratory rate, oxygen saturation, heart rate, and capillary refill time, based on the first available parameters. Discrimination was assessed by the area under the curve (AUC), sensitivity and specificity (previously defined cut-offs < 6 and ≥ 15). The outcome measure was for each setting a composite marker of high urgency. 41,917 visits from Gambia rural, 501 visits from Gambia urban, 2,608 visits from Suriname, and 1,682 visits from Tanzania were included. The proportion of high urgency was variable (range 4.6% to 24.9%). Performance ranged from AUC 0.80 (95%CI 0.70-0.89) in Gambia urban to 0.62 (95%CI 0.55-0.67) in Tanzania. The low-urgency cut-off showed a high sensitivity in all settings ranging from 0.83 (95%CI 0.81-0.84) to 1.00 (95%CI 0.97-1.00). The high-urgency cut-off showed a specificity ranging from 0.71 (95%CI 0.66-0.75) to 0.97 (95%CI 0.97-0.97). The ED-PEWS has a moderate to good performance for the recognition of high urgency children in these LMIC settings. The performance appears to have potential in improving the identification of high urgency children in LMICs.
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Affiliation(s)
- Naomi Kemps
- Department of General Paediatrics, Erasmus MC- Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Natanael Holband
- Department of Paediatrics, Academic Hospital Paramaribo, Paramaribo, Suriname
| | - Navin P. Boeddha
- Department of General Paediatrics, Erasmus MC- Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Paediatrics, Academic Hospital Paramaribo, Paramaribo, Suriname
| | - Abdoulie Faal
- Applications Development & e-Health Department, Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Amadu E. Juliana
- Department of Paediatrics, Academic Hospital Paramaribo, Paramaribo, Suriname
| | - Godfrey A. Kavishe
- National Institute of Medical Research–Mbeya Medical Research Centre, Mbeya, Tanzania
| | - Kristina Keitel
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, Bern, Switzerland
- Swiss Tropical and Public Health Institute (SwissTPH), University of Basel, Basel, Switzerland
| | | | - Elizabeth V. Ledger
- Department of Paediatrics, Bristol Royal Hospital for Children, Bristol, The United Kingdom
| | - Henriëtte A. Moll
- Department of General Paediatrics, Erasmus MC- Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Andrew M. Prentice
- Nutrition and Planetary Health Theme, Medical Research Council Unit The Gambia at the London School of Hygiene & Tropical Medicine, Banjul, The Gambia
| | - Fatou Secka
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Rainer Tan
- Swiss Tropical and Public Health Institute (SwissTPH), University of Basel, Basel, Switzerland
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Effua Usuf
- Medical Research Council Unit The Gambia at the London School of Hygiene and Tropical Medicine, Fajara, The Gambia
| | - Stefan A. Unger
- Department of Child Life and Health, University of Edinburgh, Edinburgh, The United Kingdom
| | - Joany M. Zachariasse
- Department of General Paediatrics, Erasmus MC- Sophia Children’s Hospital, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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Aguirre NL, Gutiérrez SG, Miro O, Aguiló S, Jacob J, Alquézar-Arbé A, Burillo G, Fernandez C, Llorens P, Alonso CR, Lopez IT, Cañete M, Asensio PR, Díaz BP, Pizarro TP, Navarro RJDR, Viola NP, Hernández-Castells L, Soler AC, Sánchez Fernández-Linares E, Serrano JÁS, Ezponda P, Lorenzo AM, Liarte JVO, Ramón SS, Aranda AR, Martín-Sánchez FJ, del Castillo JG. Older Adult Patients in the Emergency Department: Which Patients should be Selected for a Different Approach? Ann Geriatr Med Res 2024; 28:9-19. [PMID: 37963716 PMCID: PMC10982447 DOI: 10.4235/agmr.23.0121] [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: 08/02/2023] [Revised: 10/05/2023] [Accepted: 11/08/2023] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND While multidimensional and interdisciplinary assessment of older adult patients improves their short-term outcomes after evaluation in the emergency department (ED), this assessment is time-consuming and ill-suited for the busy environment. Thus, identifying patients who will benefit from this strategy is challenging. Therefore, this study aimed to identify older adult patients suitable for a different ED approach as well as independent variables associated with poor short-term clinical outcomes. METHODS We included all patients ≥65 years attending 52 EDs in Spain over 7 days. Sociodemographic, comorbidity, and baseline functional status data were collected. The outcomes were 30-day mortality, re-presentation, hospital readmission, and the composite of all outcomes. RESULTS During the study among 96,014 patients evaluated in the ED, we included 23,338 patients ≥65 years-mean age, 78.4±8.1 years; 12,626 (54.1%) women. During follow-up, 5,776 patients (24.75%) had poor outcomes after evaluation in the ED: 1,140 (4.88%) died, 4,640 (20.51) returned to the ED, and 1,739 (7.69%) were readmitted 30 days after discharge following the index visit. A model including male sex, age ≥75 years, arrival by ambulance, Charlson Comorbidity Index ≥3, and functional impairment had a C-index of 0.81 (95% confidence interval, 0.80-0.82) for 30-day mortality. CONCLUSION Male sex, age ≥75 years, arrival by ambulance, functional impairment, or severe comorbidity are features of patients who could benefit from approaches in the ED different from the common triage to improve the poor short-term outcomes of this population.
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Affiliation(s)
- Nere Larrea Aguirre
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
| | - Susana García Gutiérrez
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Faculty of Health Sciences, Medicine Department, University of Deusto, Bilbo, Spain
| | - Oscar Miro
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Sira Aguiló
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
| | - Javier Jacob
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
| | - Aitor Alquézar-Arbé
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
| | - Guillermo Burillo
- Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain
| | - Cesáreo Fernandez
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
| | - Pere Llorens
- Emergency Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain
| | | | | | - Mónica Cañete
- Emergency Department, Hospital Nuestra Señora del Prado de Talavera de la Reina, Toledo, Spain
| | | | | | | | | | | | | | | | | | | | - Patxi Ezponda
- Emergency Department, Hospital De Zumarraga, Guipuzcoa, Spain
| | | | | | | | | | | | | | - on behalf of the members of the SIESTA Network
- Research Unit, Galdakao-Usansolo University Hospital, Vizcaya, Spain. Kronikgune Institute for Health Services Research, Barakaldo, Spain
- Red de Investigación en Cronicidad, Atención Primaria y Prevención y Promoción de la Salud (RICAPPS), Faculty of Health Sciences, Medicine Department, University of Deusto, Bilbo, Spain
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Catalonia, Spain
- Emergency Department, Hospital de la Santa Creu I Sant Pau, Barcelona, Catalonia, Spain
- Emergency Department, Hospital Universitari de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Catalonia, Spain
- Emergency Department, Hospital Universitario de Canarias, University of La Laguna, Tenerife, Spain
- Emergency Department, Hospital Clínico San Carlos, IdISSC, Madrid, Spain
- Emergency Department, Hospital General Universitario Dr. Balmis de Alicante, Alicante, Spain
- Emergency Department, Hospital del Nalón, Langreo, Asturias, Spain
- Emergency Department, Hospital Virgen de Altagracia, Ciudad Real, Spain
- Emergency Department, Hospital Nuestra Señora del Prado de Talavera de la Reina, Toledo, Spain
- Emergency Department, Hospital Universitario Vinalopó, Alicante, Spain
- Emergency Department, Hospital Universitario de Móstoles, Madrid, Spain
- Emergency Department, Hospital Virgen del Rocio, Sevilla, Spain
- Emergency Department, Hospital General Universitario Dr. Peset, Valencia, Spain
- Emergency Department, Hospital Universitario Son Espases, Mallorca, Spain
- Emergency Department, Clinica Universitaria Navarra, Madrid, Spain
- Emergency Department, Clinico Universitario de Valencia, Valencia, Spain
- Emergency Department, Hospital Alvaro Cunqueiro, Pontevedra, Spain
- Emergency Department, Hospital Universitario de Salamanca, Salamanca, Spain
- Emergency Department, Hospital De Zumarraga, Guipuzcoa, Spain
- Emergency Department, Hospital Virxe Da Xunqueira, A Coruña, Spain
- Emergency Department, Hospital Universitario Los Arcos del Mar Menor, San Javier, Murcia, Spain
- Emergency Department, Hospital Universitario Río Ortega, Valladolid, Spain
- Emergency Department, Hospital Juan Ramón Jiménez, Huelva, Spain
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Dresden SM. Optimizing the Care of Persons Living with Dementia in the Emergency Department. Clin Geriatr Med 2023; 39:599-617. [PMID: 37798067 DOI: 10.1016/j.cger.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Emergency department (ED) care for persons living with dementia (PLWD) involves the identification of dementia or cognitive impairment, ED care which is sensitive to the specific needs of PLWD, effective communication with PLWD, their care partners, and outpatient clinicians who the patient and care-partner know and trust, and care-transitions from the emergency department to other health care settings. The recommendations in this article made based on wide-ranging heterogeneous studies of various interventions which have been studied primarily in single-site studies. Future research should work to incorporate promising findings from interventions such as hospital at home, or ED to home Care Transitions Intervention.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Center for Healthcare Studies and Outcomes Research, 211 East Ontario Street, Suite 200, Chicago, IL 60611, USA.
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Wang GQ, Gao YL, Deng P. Validation of a seven-question tool (PRISMA-7) in predicting prognosis of older adults in the emergency department: A prospective study. Am J Emerg Med 2023; 73:131-136. [PMID: 37657142 DOI: 10.1016/j.ajem.2023.08.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 08/14/2023] [Accepted: 08/14/2023] [Indexed: 09/03/2023] Open
Abstract
OBJECTIVES Older patients arrive at the emergency department (ED) with complex medical challenges, and the current ED triage models frequently undertriage the severity of illness in older adults. There is increasing awareness regarding the importance of identifying frailty in older patients in the context of urgent care. Therefore, this study aimed to assess the predictive accuracy of the seven-question tool of the Program on Research for Integrating Services of the Maintenance of Autonomy (PRISMA-7) in the ED for 28-day mortality among older adults. DESIGN A prospective polycentric observational study. SETTING West China Hospital of Sichuan University, Shangjinnanfu of West China Hospital, and People's Hospital of Henan Province. PARTICIPANTS ED patients aged ≥65 years from the three tertiary care centers over an 8-week period. PRIMARY AND SECONDARY OUTCOMES The primary outcome, 28-day all-cause mortality, was investigated using a Cox proportional hazards regression model to assess the predictive validity. The secondary endpoints, intensive care unit (ICU) transfer was investigated using multivariable logistic regression, compared with trained study assistants. RESULTS The final study population comprised 1043 consecutive patients aged ≥65 years. The area under the receiver operating characteristic (ROC) curve (AUC) for 28-day mortality was 0.80 (95% confidence interval [CI]: 0.76-0.84), 0.73 (95% CI: 0.68-0.77), and 0.78 (95% CI: 0.73-0.83) for PRISMA-7, Emergency Severity Index (ESI), and quick Sepsis Related Organ Failure Assessment (qSOFA), respectively.There was no difference in the AUC between PRISMA-7 and qSOFA(p = 0.374).The AUC for ICU admission was 0.78 (95% CI: 0.75-0.80), 0.62 (95% CI: 0.59-0.66), and 0.68 (95% CI: 0.64-0.72) for PRISMA-7, ESI, and qSOFA, respectively.The AUC for ICU admission between PRISMA-7 and ESI(p<0.001), PRISMA-7 and qSOFA(p<0.001), qSOFA and ESI(p = 0.005) was statistically significant. CONCLUSION Our findings reveal that PRISMA-7 improves the prediction of ICU admission, but there is no significant difference when it comes to all-cause mortality. PRISMA-7 appears to be a reliable and valid instrument for identifying frailty in the ED. TRIAL REGISTRATION NUMBER ChiCTR2100046545.
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Affiliation(s)
- Gui-Qun Wang
- Department of Emergency Medicine, West China Hospital, Sichuan University, China
| | - Yong-Li Gao
- Department of Emergency Medicine, West China Hospital, Sichuan University, China
| | - Peng Deng
- Department of Emergency Medicine, West China Hospital, Sichuan University, China.
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9
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Kabil G, Frost SA, Hatcher D, Shetty A, McNally S. Facilitators and barriers of appropriate and timely initiation of intravenous fluids in patients with sepsis in emergency departments: a consensus development Delphi study. BMC Nurs 2023; 22:402. [PMID: 37891553 PMCID: PMC10604401 DOI: 10.1186/s12912-023-01561-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 10/13/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Sepsis is a life-threatening medical emergency in which appropriate and timely administration of intravenous fluids to patients with features of hypotension is critical to prevent multi-organ failure and subsequent death. However, compliance with recommended fluid administration is reported to be poor. There is a lack of consensus among emergency clinicians on some of the determinant factors influencing fluid administration in sepsis. Thus, the aim of this study was to identify the level of consensus among key stakeholders in emergency departments regarding the facilitators, barriers, and strategies to improve fluid administration. METHODS The modified Delphi questionnaire with 23 statements exploring barriers, facilitators, and strategies to improve fluid administration was developed from the integration of findings from previous phases of the study involving emergency department clinicians. A two-round modified Delphi survey was conducted among key stakeholders with managerial, educational, supervision and leadership responsibilities using a "Reactive Delphi technique" from March 2023 to June 2023. The statements were rated for importance on a 9-point Likert scale. The RAND/UCLA Appropriateness Method (RAM) was used to identify the level of consensus (agreement/disagreement). RESULTS Of the 21 panellists who completed Round 1 survey, 18 (86%) also completed Round 2. The panellists rated 9 out of 10 (90%) barriers, 3 out of 4 (75%) facilitators and all 9 (100%) improvement strategies as important. Out of the total 23 statements, 18 (78%) had agreement among the panellists. Incomplete vital signs at triage (Median = 9, IQR 7.25 to 9.00) as a barrier, awareness of importance of fluid administration in sepsis (Median = 9, IQR 8.00 to 9.00) as facilitator and provision of nurse-initiated intravenous fluids (Median = 9, IQR 8.00 to 9.00) as an improvement strategy were the highest rated statements. CONCLUSION This is the first Delphi study identifying consensus on facilitators, barriers, and strategies to specifically improve intravenous fluid administration in sepsis in Australia. We identified 18 consensus-based factors associated with appropriate and timely administration of intravenous fluids in sepsis. This study offers empirical evidence to support the implementation of the identified strategies to improve patient outcomes.
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Affiliation(s)
- Gladis Kabil
- Western Sydney University, School of Nursing and Midwifery, Sydney, Australia.
- Department of Emergency, Westmead Hospital, Sydney, Australia.
| | - Steven A Frost
- South Western Sydney Nursing and Midwifery Research, Ingham Institute of Applied Medical Research, Sydney, Australia
- University of New South Wales, Sydney, Australia
- School of Nursing and Midwifery, University of Wollongong, Wollongong, Australia
| | - Deborah Hatcher
- Western Sydney University, School of Nursing and Midwifery, Sydney, Australia
| | - Amith Shetty
- Westmead Institute for Medical Research, Sydney, Australia
- NSW Ministry of Health, Sydney, Australia
| | - Stephen McNally
- Western Sydney University, School of Nursing and Midwifery, Sydney, Australia
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Supatanakij P, Imok K, Suttapanit K. Screening Tool Risk Score Assessment in the Emergency Department for Geriatric (S-TRIAGE) in 28-day mortality. Int J Emerg Med 2023; 16:60. [PMID: 37752471 PMCID: PMC10521457 DOI: 10.1186/s12245-023-00538-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 09/19/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND The number of older adults with a high risk of frailty and severe illness continues to increase. Moreover, physiological change and multiple comorbidities are challenging to triage in geriatrics. Therefore, we aimed to evaluate variables to predict 28-day mortality and develop a screening tool to predict mortality and lifesaving intervention among geriatric patients in the emergency department (ED). METHODS This study was a retrospective, single-center, observational study at the ED of Ramathibodi Hospital, Bangkok. Patients aged ≥ 65 years who visited the ED between January 2018 and December 2019 were enrolled. In the development cohort, univariable logistic regression was used to identify predictors of 28-day mortality in older patients. A predictive model for mortality and the need for lifesaving intervention was developed by multivariable logistic regression. In addition, the score was validated with internal validation and compared between development and validation set by chi-square. RESULTS We enrolled 1393 patients. In the development cohort, among these 1002 patients, 103 (10.3%) of whom died within 28 days. Malignancy, shock index (SI), systolic blood pressure (SBP) < 100 mmHg, and altered mentation were independent risk factors of 28-day mortality. We developed new screening tools named the S-TRIAGE score, which has the respiratory rate (< 11, > 22 breaths/min), the ratio of pulse oximetric saturation to the fraction of inspired oxygen (< 420, 420-450), SI (> 1, 0.6-0.99), SBP < 100 mmHg, body temperature (< 36, > 37.5 °C), and mental change. The area under a receiver operating characteristic (ROC) curve of the S-TRIAGE score in the validation cohort was 0.826 [95% confidence interval (95%CI) 0.773-0.879] in predicting mortality and lifesaving intervention, and the clinical score classified patients into five groups. CONCLUSION This study showed malignancy, hypotension, increased SI, and mental status change were predictive factors for 28-day mortality in older adults in the ED. The screening tool risk score for geriatrics used in this study is potentially a good predictor of mortality and lifesaving intervention in high-risk older patients in the ED.
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Affiliation(s)
- Praphaphorn Supatanakij
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand
| | - Kanruethai Imok
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand
| | - Karn Suttapanit
- Department of Emergency Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, 270 Rama VI Rd., Ratchathewi, Bangkok, 10400, Thailand.
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11
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James MK, Okoye A, Wahab V, Bolton S, Lee SW. Emergency Severity Index (ESI) algorithm in trauma patients: The impact of age during the pandemic. Injury 2023; 54:110875. [PMID: 37349167 DOI: 10.1016/j.injury.2023.110875] [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: 02/20/2023] [Accepted: 06/04/2023] [Indexed: 06/24/2023]
Abstract
OBJECTIVE The ESI algorithm is widely used to triage patients in the emergency room. However, few studies have assessed the reliability of ESI to accurately triage trauma patients. The aim of this study was to compare vital signs, resource utilization, and patient outcomes among trauma patients during the pandemic in 2020 vs. the previous year prior to the pandemic. METHODS This retrospective study was conducted over a 24-month period at an urban adult level one trauma center. Demographic and clinical characteristics, resource utilization, and patient outcomes were extracted from the electronic medical records and trauma registry. Trauma patients assigned ESI level 2 were stratified by age (<65 years and ≥ 65 years) and year (2019 vs. 2020) for data analysis. RESULTS A total of 3,788 trauma patients were included in the study. Males represented 68.4% (2,591) of patients and the median age was 50 years (IQR: 31, 69). The majority of patients were assigned ESI level 2 (2,162, 57.1%) and had a blunt mechanism of injury (3,122, 82.4%). In 2020, patients <65 years of age utilized less resources compared to 2019 (p < 0.001). Likewise, patients >65 years of age required less lab tests [OR: 0.1, 95% CI: (0.05 - 0.4)], IV fluids [OR: 0.2, 95% CI: (0.2 -0.3)], IV medications [OR: 0.6, 95% CI: (0.4 - 0.7)], and specialty consultations [OR: 0.4, 95% CI: (0.3 -0.5)] compared to 2019 (p < 0.0001). Within 2020, vital signs and resources utilized between younger and elderly patients varied significantly (p < 0.01). Correspondingly, the clinical outcomes between younger and elderly patients within 2020, differed significantly (p < 0.01). CONCLUSIONS The COVID-19 pandemic affected the triage of trauma patients. During 2020, patients utilized less resources compared to the previous year. Additionally, younger and elderly patients had different vital signs, resource utilization, and clinical outcomes although both being assigned ESI level 2. Younger trauma patients may have been over-triaged in 2020 due to the COVID-19 pandemic.
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Affiliation(s)
- Melissa K James
- Department of Surgery, Jamaica Hospital Medical Center, New York, United States of America
| | - Amarachukwu Okoye
- Department of Surgery, SUNY Upstate Medical University, New York, United States of America
| | - Venus Wahab
- William Carey University College of Osteopathic Medicine, Mississippi, United States of America
| | - Shadenie Bolton
- Department of Emergency Medicine, Jamaica Hospital Medical Center, New York, United States of America
| | - Shi-Wen Lee
- Department of Emergency Medicine, Jamaica Hospital Medical Center, New York, United States of America.
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12
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Markussen DL, Brevik HS, Bjørneklett RO, Engan M. Validation of a modified South African triage scale in a high-resource setting: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2023; 31:13. [PMID: 36941710 PMCID: PMC10026449 DOI: 10.1186/s13049-023-01076-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 03/04/2023] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Triage systems are widely used in emergency departments, but are not always validated. The South African Triage Scale (SATS) has mainly been studied in resource-limited settings. The aim of this study was to determine the validity of a modified version of the SATS for the general population of patients admitted to an ED at a tertiary hospital in a high-income country. The secondary objective was to study the triage performance according to age and patient categories. METHODS We conducted a retrospective cohort study of patients presenting to the Emergency Department of Haukeland University Hospital in Norway during a four-year period. We used short-term mortality, ICU admission, and the need for immediate surgery and other interventions as the primary endpoints. RESULTS A total of 162,034 emergency department visits were included in the analysis. The negative predictive value of a low triage level to exclude severe illness was 99.1% (95% confidence interval: 99.0-99.2%). The level of overtriage, defined as the proportion of patients assigned to a high triage level who were not admitted to the hospital, was 4.1% (3.9-4.2%). Receiver operating characteristic (ROC) curves showed an area under the ROC for the detection of severe illness of 0.874 (95% confidence interval: 0.870-0.879) for all patients and 0.856 (0.837-0.875), 0.884 (0.878-0.890) and 0.869 (0.862-0.876) for children, adults and elderly individuals respectively. CONCLUSION We found that the modified SATS had a good sensitivity to identify short-term mortality, ICU admission, and the need for rapid surgery and other interventions. The sensitivity was higher in adults than in children and higher in medical patients than in surgical patients. The over- and undertriage rates were acceptable.
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Affiliation(s)
- Dagfinn Lunde Markussen
- Emergency Care Clinic, Haukeland University Hospital, 5021, Bergen, Norway.
- Department of Clinical Science, University of Bergen, Postboks 7804, 5020, Bergen, Norway.
| | | | - Rune Oskar Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, 5021, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Postboks 7804, 5020, Bergen, Norway
| | - Mette Engan
- Department of Clinical Science, University of Bergen, Postboks 7804, 5020, Bergen, Norway
- Department of Paediatric and Adolescent Medicine, Haukeland University Hospital, 5021, Bergen, Norway
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13
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Joseph JW, Leventhal EL, Grossestreuer AV, Chen PC, White BA, Nathanson LA, Elhadad N, Sanchez LD. Machine Learning Methods for Predicting Patient-Level Emergency Department Workload. J Emerg Med 2023; 64:83-92. [PMID: 36450614 DOI: 10.1016/j.jemermed.2022.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 08/19/2022] [Accepted: 10/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Work Relative Value Units (wRVUs) are a component of many compensation models, and a proxy for the effort required to care for a patient. Accurate prediction of wRVUs generated per patient at triage could facilitate real-time load balancing between physicians and provide many practical operational and clinical benefits. OBJECTIVE We examined whether deep-learning approaches could predict the wRVUs generated by a patient's visit using data commonly available at triage. METHODS Adult patients presenting to an urban, academic emergency department from July 1, 2016-March 1, 2020 were included. Deidentified triage information included structured data (age, sex, vital signs, Emergency Severity Index score, language, race, standardized chief complaint) and unstructured data (free-text chief complaint) with wRVUs as outcome. Five models were examined: average wRVUs per chief complaint, linear regression, neural network and gradient-boosted tree on structured data, and neural network on unstructured textual data. Models were evaluated using mean absolute error. RESULTS We analyzed 204,064 visits between July 1, 2016 and March 1, 2020. The median wRVUs were 3.80 (interquartile range 2.56-4.21), with significant effects of age, gender, and race. Models demonstrated lower error as complexity increased. Predictions using averages from chief complaints alone demonstrated a mean error of 2.17 predicted wRVUs per visit (95% confidence interval [CI] 2.07-2.27), the linear regression model: 1.00 wRVUs (95% CI 0.97-1.04), gradient-boosted tree: 0.85 wRVUs (95% CI 0.84-0.86), neural network with structured data: 0.86 wRVUs (95% CI 0.85-0.87), and neural network with unstructured data: 0.78 wRVUs (95% CI 0.76-0.80). CONCLUSIONS Chief complaints are a poor predictor of the effort needed to evaluate a patient; however, deep-learning techniques show promise. These algorithms have the potential to provide many practical applications, including balancing workloads and compensation between emergency physicians, quantify crowding and mobilizing resources, and reducing bias in the triage process.
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Affiliation(s)
- Joshua W Joseph
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Evan L Leventhal
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Anne V Grossestreuer
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Paul C Chen
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Benjamin A White
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Larry A Nathanson
- Harvard Medical School, Boston, Massachusetts; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Noémie Elhadad
- Departments of Biomedical Informatics and Computer Science, Columbia University, New York, New York
| | - Leon D Sanchez
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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14
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Lee JH, Park YS, Kim MJ, Shin HJ, Roh YH, Kim JH, Chung HS, Park I, Chung SP. Clinical Frailty Scale as a predictor of short-term mortality: A systematic review and meta-analysis of studies on diagnostic test accuracy. Acad Emerg Med 2022; 29:1347-1356. [PMID: 35349205 DOI: 10.1111/acem.14493] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 03/11/2022] [Accepted: 03/27/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The Clinical Frailty Scale (CFS) is a representative frailty assessment tool in medicine. This systematic review and meta-analysis aimed to examine whether frailty defined based on the CFS could adequately predict short-term mortality in emergency department (ED) patients. METHODS The PubMed, EMBASE, and Cochrane libraries were searched for eligible studies until December 23, 2021. We included studies in which frailty was measured by the CFS and short-term mortality was reported for ED patients. All studies were screened by two independent researchers. Sensitivity, specificity, positive likelihood ratio (PLR), and negative likelihood ratio (NLR) values were calculated based on the data extracted from each study. Additionally, the diagnostic odds ratio (DOR) was calculated for effect size analysis, and the area under the curve (AUC) of summary receiver operating characteristics was calculated. Outcomes were in-hospital and 1-month mortality rate for patients with the CFS scores of ≥5, ≥6, and ≥7. RESULTS Overall, 17 studies (n = 45,022) were included. Although there was no evidence of publication bias, a high degree of heterogeneity was observed. For the CFS score of ≥5, the PLR, NLR, and DOR values for in-hospital mortality were 1.446 (95% confidence interval [CI] 1.325-1.578), 0.563 (95% CI 0.355-0.893), and 2.728 (95% CI 1.872-3.976), respectively. In addition, the pooled statistics for 1-month mortality were 1.566 (95% CI 1.241-1.976), 0.582 (95% CI 0.430-0.789), and 2.696 (95% CI 1.673-4.345), respectively. Subgroup analysis of trauma patients revealed that the CFS score of ≥5 could adequately predict in-hospital mortality (PLR 1.641, 95% CI 1.242-2.170; NLR 0.580, 95% CI 0.461-0.729; DOR 2.883, 95% CI 1.994-4.168). The AUC values represented sufficient to good diagnostic accuracy. CONCLUSIONS Evidence that is published to date suggests that the CFS is an accurate and reliable tool for predicting short-term mortality in emergency patients.
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Affiliation(s)
- Ji Hwan Lee
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoo Seok Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Joung Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Jung Shin
- Department of Biomedical Systems Informatics, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Republic of Korea
| | - Yun Ho Roh
- Department of Biomedical Systems Informatics, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Republic of Korea
| | - Ji Hoon Kim
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyun Soo Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Incheol Park
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Phil Chung
- Department of Emergency Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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15
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Gosselin M, Mabire C, Pasquier M, Carron PN, Hugli O, Ageron FX, Dami F. Prevalence and clinical significance of point of care elevated lactate at emergency admission in older patients: a prospective study. Intern Emerg Med 2022; 17:1803-1812. [PMID: 35678940 PMCID: PMC9178320 DOI: 10.1007/s11739-022-03005-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Patients who are over 65 years old represent up to 24% of emergency department (ED) admissions. They are at increased risk of under-triage due to impaired physiological responses. The primary objective of this study was to assess the prevalence of elevated lactate by point of care testing (POCT) in this population. The secondary objective was to assess the additional value of lactate level in predicting an early poor outcome, as compared to and combined with common clinical scores and triage scales. METHODS This monocentric prospective study recruited ED patients who were over 65 years old between July 19th 2019 and June 17th 2020. Patients consulting for seizures or needing immediate assessment were excluded. POCT lactates were considered elevated if ≥ 2.5 mmol/L. A poor outcome was defined based on certain complications or therapeutic decisions. RESULTS In total, 602 patients were included; 163 (27.1%) had elevated lactate and 44 (7.3%) had a poor outcome. There was no association between poor outcome and lactate level. Modified Early Warning Score (MEWS) was significantly associated with poor outcome, alongside National Early Warning Score (NEWS). Logistic regression also associated lactate level combined with MEWS and poor outcome. CONCLUSION The prevalence of elevated lactate was 27.1%. Lactate level alone or combined with different triage scales or clinical scores such as MEWS, NEWS and qSOFA was not associated with prediction of a poor outcome. MEWS alone performed best in predicting poor outcome. The usefulness of POCT lactate measurement at triage is questionable in the population of 65 and above.
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Affiliation(s)
- Mélanie Gosselin
- grid.9851.50000 0001 2165 4204Emergency Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Cédric Mabire
- grid.8515.90000 0001 0423 4662Institute of Higher Education and Research in Healthcare, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Mathieu Pasquier
- grid.9851.50000 0001 2165 4204Emergency Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Pierre-Nicolas Carron
- grid.9851.50000 0001 2165 4204Emergency Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Olivier Hugli
- grid.9851.50000 0001 2165 4204Emergency Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Françcois-Xavier Ageron
- grid.9851.50000 0001 2165 4204Emergency Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
| | - Fabrice Dami
- grid.9851.50000 0001 2165 4204Emergency Department, Lausanne University Hospital, University of Lausanne, 1011 Lausanne, Switzerland
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Kemp K, Alakare J, Kätkä M, Lääperi M, Lehtonen L, Castrén M. Accuracy of Emergency Severity Index in older adults. Eur J Emerg Med 2022; 29:204-209. [PMID: 34954725 PMCID: PMC9042339 DOI: 10.1097/mej.0000000000000900] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/05/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND IMPORTANCE Emergency Severity Index is a five-level triage tool in the emergency department that predicts the need for emergency department resources and the degree of emergency. However, it is unknown whether this is valid in patients aged greater than or equal to 65 years. OBJECTIVE The aim of the study was to compare the accuracy of the Emergency Severity Index triage system between emergency department patients aged 18-64 and greater than or equal to 65 years. DESIGN, SETTINGS, AND PARTICIPANTS This was a retrospective observational cohort study of adults who presented to a Finnish emergency department between 1 February 2018 and 28 February 2018. All data were collected from electronic health records. OUTCOME MEASURES AND ANALYSIS The primary outcome was 3-day mortality. The secondary outcomes were 30-day mortality, hospital admission, high dependency unit or ICU admission, and emergency department length of stay. The area under the receiver operating characteristic curve and cutoff performances were used to investigate significant associations between triage categories and outcomes. The results of the two age groups were compared. MAIN RESULTS There were 3141 emergency department patients aged 18-64 years and 2370 patients aged greater than or equal to 65 years. The 3-day mortality area under the curve in patients aged greater than or equal to 65 years was greater than that in patients aged 18-64 years. The Emergency Severity Index was associated with high dependency unit/ICU admissions in both groups, with moderate sensitivity [18-64 years: 61.8% (50.9-71.9%); greater than or equal to 65 years: 73.3% (63.5-81.6%)] and high specificity [18-64 years: 93.0% (92.0-93.8%); greater than or equal to 65 years: 90.9% (90.0-92.1%)]. The sensitivity was high and specificity was low for 30-day mortality and hospital admission in both age groups. The emergency department length of stay was the longest in Emergency Severity Index category 3 for both age groups. There was no significant difference in accuracy between age groups for any outcome. CONCLUSION Emergency Severity Index performed well in predicting high dependency unit/ICU admission rates for both 18-64 years and greater than or equal to 65-year-old patients. It predicted the 3-day mortality for patients aged greater than or equal to 65 years with high accuracy. It was inaccurate in predicting 30-day mortality and hospital admission for both age groups.
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Affiliation(s)
- Kirsi Kemp
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki Meilahden tornisairaala, Helsinki
| | - Janne Alakare
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki Meilahden tornisairaala, Helsinki
- Geriatric Acute Care, City of Espoo
| | - Minna Kätkä
- Department of Emergency Medicine, Tampere University Hospital and University of Tampere, Tampere
| | - Mitja Lääperi
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki Meilahden tornisairaala, Helsinki
| | - Lasse Lehtonen
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maaret Castrén
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki Meilahden tornisairaala, Helsinki
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Völk S, Koedel U, Horster S, Bayer A, D'Haese JG, Pfister HW, Klein M. Patient disposition using the Emergency Severity Index: a retrospective observational study at an interdisciplinary emergency department. BMJ Open 2022; 12:e057684. [PMID: 35551090 PMCID: PMC9109098 DOI: 10.1136/bmjopen-2021-057684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Early patient disposition is crucial to prevent crowding in emergency departments (EDs). Our study aimed to characterise the need of in-house resources for patients treated in the ED according to the Emergency Severity Index (ESI) and the presenting complaint at the timepoint of triage. DESIGN A retrospective single-centre study was conducted. SETTING Data of all patients who presented to the interdisciplinary ED of a tertiary care hospital in Munich, Germany, from 2014 to 2017 were analysed. PARTICIPANTS n=113 694 patients were included. MEASURES ESI Score, medical speciality according to the chief complaint, mode of arrival, admission rates and discharge destination from the ED were evaluated. RESULTS Patient disposition varied according to ESI scores in combination with the chief complaint. Patients with low ESI scores were more likely to be admitted after treatment in the ED than patients with high ESI scores. Highly prioritised patients (ESI 1) mainly required admission to an intensive care unit (ICU, 27%), intermediate care unit (IMC, 37%) or immediate intervention (11%). In this critical patient group, 30% of patients with neurological or medical symptoms required immediate intensive care, whereas only 17% of patients with surgical problems were admitted to an ICU. A significant number of patients (particularly with neurological or medical problems) required hospital (and in some cases even ICU or IMC) admission despite high ESI scores. CONCLUSIONS Overall, ESI seems to be a useful tool to anticipate the need for specialised in-hospital resources on arrival. Patients with symptoms pointing at neurological or medical problems need particular attention as ESI may fail to sufficiently predict the care facility level for this patient group.
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Affiliation(s)
- Stefanie Völk
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Uwe Koedel
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Sophia Horster
- Emergency Department, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Andreas Bayer
- Department of Anaesthesiology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Jan G D'Haese
- Department of General, Visceral and Transplantation Surgery, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Hans-Walter Pfister
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
| | - Matthias Klein
- Department of Neurology, University Hospital, Ludwig Maximilians University, Munich, Germany
- Emergency Department, University Hospital, Ludwig Maximilians University, Munich, Germany
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18
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Heppner HJ, Haitham H. Intensive care of geriatric patients-a thin line between under- and overtreatment. Wien Med Wochenschr 2022; 172:102-108. [PMID: 35006520 PMCID: PMC8744379 DOI: 10.1007/s10354-021-00902-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 11/30/2021] [Indexed: 11/25/2022]
Abstract
Demographic developments are leading to an ever-increasing proportion of elderly and aged patients in hospitals at all levels of care, and even more patients from these age groups are to be expected in the future. Based on the projected population development, e.g., in Norway, an increase in intensive care beds of between 26 and 37% is expected by 2025. This poses special challenges for the treatment and management of geriatric intensive care patients. The acute illness is not the only decisive factor, but rather the existing multimorbidity and functional limitations of this vulnerable patient group must likewise be taken into account. Age per se is not the sole determinant of prognosis in critical patients, even though mortality increases with age.
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Affiliation(s)
- Hans Jürgen Heppner
- Chair for Geriatrics and Day-Care Hospital, University of Witten/Herdecke, Dr.-Moeller-Str. 15, 58332, Schwelm, Germany.
- Geriatric Clinic, Schwelm, Germany.
- Institute for Biomedicine of Ageing, FAU Erlangen, Nuremberg, Germany.
| | - Hag Haitham
- Chair for Geriatrics and Day-Care Hospital, University of Witten/Herdecke, Dr.-Moeller-Str. 15, 58332, Schwelm, Germany
- Geriatric Clinic, Schwelm, Germany
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Kemp K, Alakare J, Kätkä M, Lääperi M, Lehtonen L, Castrén M. Effect of age adjustment on two triage methods. BMC Emerg Med 2022; 22:52. [PMID: 35346062 PMCID: PMC8961917 DOI: 10.1186/s12873-022-00600-0] [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] [Received: 09/29/2021] [Accepted: 03/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Most emergency departments rely on acuity assessment, triage, to recognize critically ill patients that need urgent treatment, and to allocate resources according to need. The accuracy of commonly used triage instruments such as the Emergency Severity Index (ESI) is lower for older adults compared to young patients. We aim to examine, whether adjusting the triage category by age leads to improvement in sensitivity without excessive increase in patient numbers in the higher triage categories. The primary outcome measure was 3-day mortality and secondary outcomes were 30-day mortality, hospital admission, and HDU/ICU admissions.
Methods
We gathered data of all adult patients who had an unscheduled visit to any of our three emergency departments within one month. The data was analysed for 3-day mortality, 30-day mortality, hospital admission, and high dependency unit or intensive care unit (HDU/ICU) admission. The analysis was run for both the standard ESI triage method and a local 3-level Helsinki University Hospital (HUH) method. A further analysis was run for both triage methods with age adjustment. Net reclassification improvement values were calculated to demonstrate the effect of age adjustment.
Results
Thirteen thousand seven hundred fifty-nine patients met the study criteria, median age was 57. 3-day mortality AUCs for unadjusted HUH and ESI triage were 0.77 (0.65–0.88) and 0.72 (0.57–0.87); 30-day mortality AUCs were 0.64 (0.59–0.69) and 0.69 (0.64–0.73); hospital admission AUCs were 0.60 (0.68–0.71) and 0.66 (0.65–0.68) and HDU/ICU admission AUCs were 0.67 (0.64–0.70) and 0.82 (0.79–0.86), respectively. Age adjustment improved accuracy for 30-day mortality and hospital admission. With the threshold age of 80, AUCs for 30-day mortality were 0.73 (0.68–0.77) and 0.77 (0.73–0.81) and for hospital admission, 0.66 (0.65–0.67) and 0.72 (0.71–0.73) for the HUH and ESI triage. The effect was similar with all cut off ages.
Conclusion
Moving older adults into a more urgent triage category based on age, improved the triage instruments’ performance slightly in predicting 30-day mortality and hospital admission without excessive increase in patient numbers in the higher triage categories. Age adjustment did not improve HDU/ICU admission or 3-day mortality prediction.
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20
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Friedman AB, Chen AT, Wu R, Coe NB, Halpern SD, Hwang U, Kelz RR, Cappola AR. Evaluation and disposition of older adults presenting to the emergency department with abdominal pain. J Am Geriatr Soc 2022; 70:501-511. [PMID: 34628638 PMCID: PMC10078825 DOI: 10.1111/jgs.17503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 08/30/2021] [Accepted: 09/12/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Abdominal pain is the most common chief complaint in US emergency departments (EDs) among patients over 65, who are at high risk of mortality or incident disability after the ED encounter. We sought to characterize the evaluation, management, and disposition of older adults who present to the ED with abdominal pain. METHODS We performed a survey-weighted analysis of the National Hospital Ambulatory Medical Care Survey (NHAMCS), comparing older adults with a chief complaint of abdominal pain to those without. Visits from 2013 to 2017 to nationally representative EDs were included. We analyzed 81,509 visits to 1211 US EDs, which projects to 531,780,629 ED visits after survey weighting. We report the diagnostic testing, evaluation, management, additional reasons for visit, and disposition of ED visits. RESULTS Among older adults (≥65 years), 7% of ED visits were for abdominal pain. Older patients with abdominal pain had a lower probability of being triaged to the "Emergent" (ESI2) acuity on arrival (7.1% vs. 14.8%) yet were more likely to be admitted directly to the operating room than older adults without abdominal pain (3.6% vs. 0.8%), with no statistically significant differences in discharge home, death, or admission to critical care. Ultrasound or CT imaging was performed in 60% of older adults with abdominal pain. A minority (39%) of older patients with abdominal pain received an electrocardiogram (EKG). CONCLUSIONS Abdominal pain in older adults presenting to EDs is a serious condition yet is triaged to "emergent" acuity at half the rate of other conditions. Opportunities for improving diagnosis and management may exist. Further research is needed to examine whether improved recognition of abdominal pain as a syndromic presentation would improve patient outcomes.
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Affiliation(s)
- Ari B. Friedman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Angela T. Chen
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Rachel Wu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Norma B. Coe
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Scott D. Halpern
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Ula Hwang
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
- Geriatrics Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, New York, USA
| | - Rachel R. Kelz
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Anne R. Cappola
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Boreskie KF, Hay JL, Boreskie PE, Arora RC, Duhamel TA. Frailty-aware care: giving value to frailty assessment across different healthcare settings. BMC Geriatr 2022; 22:13. [PMID: 34979966 PMCID: PMC8722007 DOI: 10.1186/s12877-021-02722-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 12/15/2021] [Indexed: 12/14/2022] Open
Abstract
Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.
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Affiliation(s)
- Kevin F Boreskie
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada.
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada.
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Jacqueline L Hay
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
| | - Patrick E Boreskie
- Department of Emergency Medicine, Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rakesh C Arora
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Todd A Duhamel
- Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada
- Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada
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Rashid K, Ullah M, Ahmed ST, Sajid MZ, Hayat MA, Nawaz B, Abbas K. Accuracy of Emergency Room Triage Using Emergency Severity Index (ESI): Independent Predictor of Under and Over Triage. Cureus 2021; 13:e20229. [PMID: 35004046 PMCID: PMC8730791 DOI: 10.7759/cureus.20229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2021] [Indexed: 11/05/2022] Open
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23
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Vergara P, Forero D, Bastidas A, Garcia JC, Blanco J, Azocar J, Bustos RH, Liebisch H. Validation of the National Early Warning Score (NEWS)-2 for adults in the emergency department in a tertiary-level clinic in Colombia: Cohort study. Medicine (Baltimore) 2021; 100:e27325. [PMID: 34622831 PMCID: PMC8500632 DOI: 10.1097/md.0000000000027325] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 09/07/2021] [Indexed: 01/05/2023] Open
Abstract
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.
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Affiliation(s)
- Peter Vergara
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
- Clinical Pharmacology Service, Clínica Universidad de La Sabana, Colombia
| | - Daniela Forero
- Faculty of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Alirio Bastidas
- Research Department, Faculty of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Julio-Cesar Garcia
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
- Clinical Pharmacology Service, Clínica Universidad de La Sabana, Colombia
| | - Jhosep Blanco
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
| | - Jorge Azocar
- Faculty of Medicine, Universidad de La Sabana, Chía, Colombia
| | - Rosa-Helena Bustos
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
| | - Hans Liebisch
- Evidence-based Therapeutics Group, Clinical Pharmacology, Universidad de La Sabana, Clínica Universidad de La Sabana, Chía, Colombia
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24
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The Undertriage of Older Adults in the Emergency Department: A Review of Interventions. Adv Emerg Nurs J 2021; 43:178-185. [PMID: 34397492 DOI: 10.1097/tme.0000000000000359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse and the emergency nurse and to assist with the translation of research into practice. A topic and a research study are selected for each column. A patient scenario is presented as a vehicle, in which to review and critique, the findings of the selected research study. In this column, we review the conclusions of A. Malinovska, L. Pitasch, N. Geigy, C. H. Nickel, and R. Bingisser (2019) from their article, titled "Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients."
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25
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Chen RF, Cheng KC, Lin YY, Chang IC, Tsai CH. Predicting Unscheduled Emergency Department Return Visits Among Older Adults: Population-Based Retrospective Study. JMIR Med Inform 2021; 9:e22491. [PMID: 34319244 PMCID: PMC8367131 DOI: 10.2196/22491] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/11/2021] [Accepted: 06/17/2021] [Indexed: 11/29/2022] Open
Abstract
Background Unscheduled emergency department return visits (EDRVs) are key indicators for monitoring the quality of emergency medical care. A high return rate implies that the medical services provided by the emergency department (ED) failed to achieve the expected results of accurate diagnosis and effective treatment. Older adults are more susceptible to diseases and comorbidities than younger adults, and they exhibit unique and complex clinical characteristics that increase the difficulty of clinical diagnosis and treatment. Older adults also use more emergency medical resources than people in other age groups. Many studies have reviewed the causes of EDRVs among general ED patients; however, few have focused on older adults, although this is the age group with the highest rate of EDRVs. Objective This aim of this study is to establish a model for predicting unscheduled EDRVs within a 72-hour period among patients aged 65 years and older. In addition, we aim to investigate the effects of the influencing factors on their unscheduled EDRVs. Methods We used stratified and randomized data from Taiwan’s National Health Insurance Research Database and applied data mining techniques to construct a prediction model consisting of patient, disease, hospital, and physician characteristics. Records of ED visits by patients aged 65 years and older from 1996 to 2010 in the National Health Insurance Research Database were selected, and the final sample size was 49,252 records. Results The decision tree of the prediction model achieved an acceptable overall accuracy of 76.80%. Economic status, chronic illness, and length of stay in the ED were the top three variables influencing unscheduled EDRVs. Those who stayed in the ED overnight or longer on their first visit were less likely to return. This study confirms the results of prior studies, which found that economically underprivileged older adults with chronic illness and comorbidities were more likely to return to the ED. Conclusions Medical institutions can use our prediction model as a reference to improve medical management and clinical services by understanding the reasons for 72-hour unscheduled EDRVs in older adult patients. A possible solution is to create mechanisms that incorporate our prediction model and develop a support system with customized medical education for older patients and their family members before discharge. Meanwhile, a reasonably longer length of stay in the ED may help evaluate treatments and guide prognosis for older adult patients, and it may further reduce the rate of their unscheduled EDRVs.
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Affiliation(s)
- Rai-Fu Chen
- Department of Information Management, Chia-Nan University of Pharmacy and Science, Tainan City, Taiwan
| | - Kuei-Chen Cheng
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Yu-Yin Lin
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - I-Chiu Chang
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan
| | - Cheng-Han Tsai
- Department of Information Management, National Chung Cheng University, Chiayi County, Taiwan.,Department of Emergency, Chiayi Branch, Taichung Veterans General Hospital, Chiayi City, Taiwan
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26
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Whate A, Elliott J, Carter D, Stolee P. Performance of the interRAI ED Screener for Risk-Screening in Older Adults Accessing Paramedic Services. Can Geriatr J 2021; 24:8-13. [PMID: 33680258 PMCID: PMC7904328 DOI: 10.5770/cgj.24.451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background Paramedics respond to a significant number of non-emergency calls generated by older adults each year. Paramedics routinely assess and screen older adults to determine risk level and need for additional follow-up. This project implemented the interRAI ED Screener into routine care to determine whether the screener and resulting Assessment Urgency Algorithm (AUA) score is useful in predicting adverse outcomes. Methods We conducted a population-based retrospective study using administrative health data for patients aged 65+ assessed by paramedics from July 2016 to February 2017. Patients were assigned an AUA score and classified into three risk categories. Outcome data including hospitalizations, Emergency Department (ED) visits, home care status, and survival were collected and compared across AUA risk categories using descriptive and analytical statistics. Results Of the 2,801 patients screened, 31.9% were classified as high risk, 23.6% as moderate risk, and 44.6% as low risk. Patients who scored in the highest risk category were found to have longer hospital stays, and were more likely to require home care (p<.0001). The AUA risk category also predicted survival (p<.001). Conclusions The AUA predicted multiple adverse outcomes in this population. Use of the AUA by paramedics may aid in earlier identification of those in need of additional intervention and services.
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Affiliation(s)
- Alexandra Whate
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
| | - Jacobi Elliott
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - Dustin Carter
- Community Paramedicine, Middlesex-London Paramedic Service, London, ON, Canada
| | - Paul Stolee
- School of Public Health and Health Systems, University of Waterloo, Waterloo, ON, Canada
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Kemp K, Mertanen R, Niemi-Murola L, Lehtonen L, Castrén M. A common definition should be used in future studies of NSC. Scand J Trauma Resusc Emerg Med 2021; 29:33. [PMID: 33593405 PMCID: PMC7885594 DOI: 10.1186/s13049-021-00851-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Accepted: 02/05/2021] [Indexed: 11/10/2022] Open
Affiliation(s)
- Kirsi Kemp
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland.
| | - Reija Mertanen
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
| | - Leila Niemi-Murola
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lasse Lehtonen
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maaret Castrén
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
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28
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AlSerkal Y, AlBlooshi K, AlBlooshi S, Khan Y, Naqvi SA, Fincham C, AlMehiri N. Triage Accuracy and Its Association with Patient Factors Using Emergency Severity Index: Findings from United Arab Emirates. Open Access Emerg Med 2020; 12:427-434. [PMID: 33299359 PMCID: PMC7718980 DOI: 10.2147/oaem.s263805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/19/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction The Ministry of Health and Prevention of the UAE acquired an electronic medical record system (Wareed) through which they incorporated the Emergency Severity Index as the standard triaging tool. This raised the need to review population dynamics and the accuracy of triage performed by the health-care providers utilizing the tool. Objective This research aimed to study demographics and dynamics of the population presenting to emergency departments (EDs) during 2018, evaluate the accuracy of triage assessment using comparative analysis techniques, and determine relationships between patient factors (severity of illness, age-group) and the accuracy of triage. Methods This was an observational study that aimed to ascertain findings from ED data over 1 year (January 2018-December 2018) and explore factors associated with reduced accuracy in acuity assignment. We employed comparative analysis to measure the level of agreement between standard guidelines and local findings. Results A total of 576,154 patients visited EDs in 2018, of which 54.4% were male. A statistically significant increase in length of stay with increasing severity of illness was observed (Kruskal-Wallis test). Overall triage accuracy was 41.6%, with a positive association with increasing severity of illness. We found a positive association between severity of illness and accuracy of triage (OR 0.14, p=0). We also found on logistic regression that the age-group 11-20 years had the highest probability of accurate triage acuity (R 2=0.41, p=0). Conclusion Conducted on a very large data set from the UAE, our study reflects upon population dynamics and triage accuracy distribution among different variables. This study paves the way for further in-depth analysis of factors that may impact triage accuracy within EDs, and utilizing a similar approach it can be replicated in other settings as well.
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Affiliation(s)
- Yousif AlSerkal
- Hospital Sector, Ministry of Health and Prevention, Dubai, United Arab Emirates
| | - Kalthoom AlBlooshi
- Hospital Department, Ministry of Health and Prevention, Dubai, United Arab Emirates
| | - Sumaya AlBlooshi
- Nursing Department, Ministry of Health and Prevention, Dubai, United Arab Emirates
| | - Yasir Khan
- Cerner Middle East, Dubai, United Arab Emirates
| | | | | | - Noor AlMehiri
- Hospital Department, Ministry of Health and Prevention, Dubai, United Arab Emirates
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29
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Cheung KY, Leung LP. Validity and reliability of the triage scale in older people in a regional emergency department in Hong Kong. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920971633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Older people (⩾65 years) present a unique challenge in emergency department triage. Hong Kong’s Hospital Authority adopts a five-level emergency department triage system, with no special considerations for older people. We evaluated the validity and reliability of this triage scale in older people in a regional Hong Kong emergency department. Methods: In total, 295 cases stratified by triage category were randomly selected for review from November 2016 to January 2017. Validity was established by comparing the real emergency department patients’ triage category against (1) that of an expert panel and (2) the need for life-saving intervention. Triage notes were extracted to make case scenarios to evaluate inter- and intra-rater reliabilities. Emergency department nurses (n = 8) were randomly selected and grouped into <5 and ⩾5 years emergency department experience. All nurses independently rated all 295 scenarios, blinded to clinical outcomes. Results: The percentage agreement between the real emergency department patients’ triage category and the expert panel’s assignment was 68.5%, with 16.3% and 15.3% over-triage and under-triage, respectively. Quadratic weighting kappa for agreement with the expert panel was 0.72 (95% confidence interval: 0.53–0.91). The sensitivity, specificity and positive likelihood ratio for the need for life-saving interventions were 75.0% (95% confidence interval: 47.6%–92.7%), 97.1% (95% confidence interval: 94.4%–98.8%) and 26.2 (95% confidence interval: 12.5%–54.8%), respectively. The Fleiss kappa value for inter-rater reliability was 0.50 (95% confidence interval: 0.47–0.54) for junior and senior nurse groups, respectively. Conclusion: The current triage scale demonstrates reasonable validity and reliability for use in our older people. Considerations highlighting the unique characteristics of older people emergency department presentations are recommended.
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Affiliation(s)
- Kai Yeung Cheung
- Accident and Emergency Department, United Christian Hospital, Kowloon, Hong Kong
| | - Ling Pong Leung
- Emergency Medicine Unit, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Pok Fu Lam, Hong Kong
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30
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Ginsburg AD, Oliveira J E Silva L, Mullan A, Mhayamaguru KM, Bower S, Jeffery MM, Bellolio F. Should age be incorporated into the adult triage algorithm in the emergency department? Am J Emerg Med 2020; 46:508-514. [PMID: 33191046 DOI: 10.1016/j.ajem.2020.10.075] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 10/27/2020] [Accepted: 10/31/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To compare resource utilization and mortality between older and younger adult patients with similar ED chief complaints and ESI triage levels. METHODS This was an observational study of consecutive adult patients (age ≥ 40) who presented to an academic ED over a 1-year period with chest pain, abdominal pain, altered mental status, generalized weakness, or headache. Patients were categorized into 40-64, 65-79, and ≥ 80-year old groups. Mortality and utilization outcomes were compared between age groups through logistic regression models or Cox proportional hazards adjusting for ESI level and chief complaint. Odds ratios (OR) and hazard ratios (HR) were calculated with 95% confidence intervals (CI). RESULTS A total of 9798 ED visits were included. As compared to younger adults (age 40-64), older adults, independently of ESI level and chief complaint, had higher ED laboratory use (OR 1.46 [CI 1.29, 1.66] for age 65-80; OR 1.33 [CI 1.15, 1.55] for age ≥ 80), ED radiology use (OR 1.40 [CI 1.26, 1.56]; OR 1.48 [CI 1.30, 1.69]), hospital admission (OR 1.56 [CI 1.42, 1.72]; OR 1.97 [CI 1.75, 2.21]), and ICU admission (OR 1.38 [CI 1.15, 1.65]; OR 1.23 [CI 0.99, 1.52]). Despite similar ESI and chief complaint, patients age 65-79 and ≥ 80 had higher 30-day mortality rates (HR 1.87 [CI 1.39 to 2.51] and 2.47 [CI 1.81 to 3.37], respectively). CONCLUSIONS Older adults with similar chief complaints and ESI levels than younger adults, have significantly higher ED resource use, hospitalization rates, and mortality.
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Affiliation(s)
| | | | - Aidan Mullan
- Department of Biostatistics and Informatics, Mayo Clinic, Rochester, MN, USA
| | | | - Susan Bower
- Department of Nursing, Mayo Clinic, Rochester, MN, USA
| | - Molly M Jeffery
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN, USA; Department of Health Science Research, Division of Health Care Policy and Research, Mayo Clinic, Rochester, MN, USA.
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Kemp K, Alakare J, Harjola VP, Strandberg T, Tolonen J, Lehtonen L, Castrén M. National Early Warning Score 2 (NEWS2) and 3-level triage scale as risk predictors in frail older adults in the emergency department. BMC Emerg Med 2020; 20:83. [PMID: 33115446 PMCID: PMC7594283 DOI: 10.1186/s12873-020-00379-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of the emergency department (ED) triage is to recognize critically ill patients and to allocate resources. No strong evidence for accuracy of the current triage instruments, especially for the older adults, exists. We evaluated the National Early Warning Score 2 (NEWS2) and a 3-level triage assessment as risk predictors for frail older adults visiting the ED. METHODS This prospective, observational study was performed in a Finnish ED. The data were collected in a six-month period and included were ≥ 75-year-old residents with Clinical Frailty Scale score of at least four. We analyzed the predictive values of NEWS2 and the three-level triage scale for 30-day mortality, hospital admission, high dependency unit (HDU) and intensive care unit (ICU) admissions, a count of 72-h and 30-day revisits, and ED length-of-stay (LOS). RESULTS A total of 1711 ED visits were included. Median for age, CFS, LOS and NEWS2 were 85 years, 6 points, 6.2 h and 1 point, respectively. 30-day mortality was 96/1711. At triage, 69, 356 and 1278 of patients were assessed as red, yellow and green, respectively. There were 1103 admissions, of them 31 to an HDU facility, none to ICU. With NEWS2 and triage score, AUCs for 30-day mortality prediction were 0.70 (0.64-0.76) and 0.62 (0.56-0.68); for hospital admission prediction 0.62 (0.60-0.65) and 0.55 (0.52-0.56), and for HDU admission 0.72 (0.61-0.83) and 0.80 (0.70-0.90), respectively. The NEWS2 divided into risk groups of low, medium and high did not predict the ED LOS (p = 0.095). There was a difference in ED LOS between the red/yellow and as red/green patient groups (p < 0.001) but not between the yellow/green groups (p = 0.59). There were 48 and 351 revisits within 72 h and 30 days, respectively. With NEWS2 AUCs for 72-h and 30-day revisit prediction were 0.48 (95% CI 0.40-0.56) and 0.47 (0.44-0.51), respectively; with triage score 0.48 (0.40-0.56) and 0.49 (0.46-0.52), respectively. CONCLUSIONS The NEWS2 and a local 3-level triage scale are statistically significant, but poor in accuracy, in predicting 30-day mortality, and HDU admission but not ED LOS or revisit rates for frail older adults. NEWS2 also seems to predict hospital admission.
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Affiliation(s)
- Kirsi Kemp
- Emergency Medicine, Helsinki University, Helsinki, Finland. .,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland.
| | - Janne Alakare
- Emergency Medicine, Helsinki University, Helsinki, Finland.,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Veli-Pekka Harjola
- Emergency Medicine, Helsinki University, Helsinki, Finland.,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Timo Strandberg
- University of Helsinki, Clinicum, and Helsinki University Hospital, Helsinki, Finland.,University of Oulu, Center for Life Course Health Research, Oulu, Finland
| | - Jukka Tolonen
- Emergency Medicine, Helsinki University, Helsinki, Finland.,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - Lasse Lehtonen
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maaret Castrén
- Emergency Medicine, Helsinki University, Helsinki, Finland.,Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
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Joseph JW, Leventhal EL, Grossestreuer AV, Wong ML, Joseph LJ, Nathanson LA, Donnino MW, Elhadad N, Sanchez LD. Deep-learning approaches to identify critically Ill patients at emergency department triage using limited information. J Am Coll Emerg Physicians Open 2020; 1:773-781. [PMID: 33145518 PMCID: PMC7593422 DOI: 10.1002/emp2.12218] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/09/2020] [Accepted: 07/22/2020] [Indexed: 12/23/2022] Open
Abstract
STUDY OBJECTIVE Triage quickly identifies critically ill patients, facilitating timely interventions. Many emergency departments (EDs) use emergency severity index (ESI) or abnormal vital sign triggers to guide triage. However, both use fixed thresholds, and false activations are costly. Prior approaches using machinelearning have relied on information that is often unavailable during the triage process. We examined whether deep-learning approaches could identify critically ill patients only using data immediately available at triage. METHODS We conducted a retrospective, cross-sectional study at an urban tertiary care center, from January 1, 2012-January 1, 2020. De-identified triage information included structured (age, sex, initial vital signs) and textual (chief complaint) data, with critical illness (mortality or ICU admission within 24 hours) as the outcome. Four progressively complex deep-learning models were trained and applied to triage information from all patients. We compared the accuracy of the models against ESI as the standard diagnostic test, using area under the receiver-operator curve (AUC). RESULTS A total of 445,925 patients were included, with 60,901 (13.7%) critically ill. Vital sign thresholds identified critically ill patients with AUC 0.521 (95% confidence interval [CI] = 0.519-0.522), and ESI <3 demonstrated AUC 0.672 (95% CI = 0.671-0.674), logistic regression classified patients with AUC 0.803 (95% CI = 0.802-0.804), 2-layer neural network with structured data with AUC 0.811 (95% CI = 0.807-0.815), gradient tree boosting with AUC 0.820 (95% CI = 0.818-0.821), and the neural network model with textual data with AUC 0.851 (95% CI = 0.849-0.852). All successive increases in AUC were statistically significant. CONCLUSION Deep-learning techniques represent a promising method of augmenting triage, even with limited information. Further research is needed to determine if improved predictions yield clinical and operational benefits.
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Affiliation(s)
- Joshua W. Joseph
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Evan L. Leventhal
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Anne V. Grossestreuer
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Matthew L. Wong
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Loren J. Joseph
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of PathologyBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Larry A. Nathanson
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Michael W. Donnino
- Harvard Medical SchoolBostonMassachusettsUSA
- Department of Emergency MedicineDivision of Pulmonary and Critical Care MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
| | - Noémie Elhadad
- Departments of Biomedical Informatics and Computer ScienceColumbia UniversityNew YorkNew YorkUSA
| | - Leon D. Sanchez
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Wachtel G, Elalouf A. Addressing overcrowding in an emergency department: an approach for identifying and treating influential factors and a real-life application. Isr J Health Policy Res 2020; 9:37. [PMID: 32873328 PMCID: PMC7550853 DOI: 10.1186/s13584-020-00390-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 05/28/2020] [Indexed: 11/16/2022] Open
Abstract
Background Overcrowding in hospital emergency departments that arises from long length-of-stay is an unfortunate common occurrence. While some factors affecting length-of-stay are well known, there may be additional factors that have not yet been properly addressed. This research offers a method for emergency department managers to use available data from their departments to identify new factors that significantly influence emergency departments crowding and patient length-of-stay. Methods We propose an algorithm that can assist emergency department managers in determining which of these factors to address, given budgetary constraints. We implemented it in a case study which takes into account factors that are known to be influential, e.g., reason for arrival, occupancy in the emergency department, and arrival time, as well as factors that are explored for the first time in this paper, such as patient heart rate, the number of accompanying escorts, and the number of tests assigned to patients (e.g., blood tests and urinalysis). Results All the implemented and new factors are shown to have a significant influence on the length-of-stay and crowding. We also obtained additional support for our results by interviewing emergency departments physicians and nurses from various hospitals. Conclusions It is expected that, by taking all the above factors into consideration, emergency departments efficiency can be improved. The algorithm constructed here allows the choice of the most cost-effective factors to be improved, subject to a given budget. We have been able to derive practical recommendations that emergency departments managers might use to limit crowding and patient length-of-stay.
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Affiliation(s)
- Guy Wachtel
- Department of Management, Bar-Ilan University, 5290002, Ramat Gan, Israel.
| | - Amir Elalouf
- Department of Management, Bar-Ilan University, 5290002, Ramat Gan, Israel
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Ganjali R, Golmakani R, Ebrahimi M, Eslami S, Bolvardi E. Accuracy of the Emergency Department Triage System using the Emergency Severity Index for Predicting Patient Outcome; A Single Center Experience. Bull Emerg Trauma 2020; 8:115-120. [PMID: 32420397 PMCID: PMC7211387 DOI: 10.30476/beat.2020.46452] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate the accuracy of the five-level triage system using the emergency severity index (ESI) and to determine the compliance of the triage level with patient outcomes. Methods This was a cross-sectional study which was performed in the emergency department of Imam Reza Hospital of Mashhad during 2017. We included all the adult patients (≥15 years of age) referring to the emergency department. The data were recorded in a questionnaire containing three sections including demographic information, results of triage by ESI and final outcome of the patient. Patients referred to the triage unit were simultaneously triaged by triage nurse and some emergency medicine physicians. The triage was performed by a nurse with an emergency medicine physician (EMP) was considered as a gold standard and the outcome was compared in 24 hours later. Results Overall, we included 400 patients with a mean age of 46.40 ± 18.52 years among whom there were 211 (52.8%) men and 189 (47.3%) women. Finally, 123 patients were hospitalized, 12 died, 256 were discharged by a physician, and 9 people left the hospital with their own consent. The calculated weight kappa was used to determine the agreement between the observers (nurse triage and physician) at 0.701 so that the agreement between the triage performed by a nurse and an EMP was in an excellent level (p<0.001). There was a significant relationship between the triage levels (determined by physicians) and the outcome of the patient (p<0.001), and the five-level system had a high overlap and significant relation with patient's outcome. Conclusion The results of the current study revealed that the five-level triage system using the ESI has a high accuracy in triage and estimates the patient outcomes effectively and thus, could be used as an effective system in hospital triage.
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Affiliation(s)
- Raheleh Ganjali
- Medical Informatics, Department of medical informatics, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reza Golmakani
- Department of Emergency Medicine, Doctor Shariati Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Ebrahimi
- Department of Emergency Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Saeid Eslami
- Pharmaceutical Research Centre, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran.,Department of Medical Informatics University of Amsterdam, Amsterdam, The Netherlands
| | - Ehsan Bolvardi
- Department of Emergency Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Blomaard LC, Speksnijder C, Lucke JA, de Gelder J, Anten S, Schuit SCE, Steyerberg EW, Gussekloo J, de Groot B, Mooijaart SP. Geriatric Screening, Triage Urgency, and 30-Day Mortality in Older Emergency Department Patients. J Am Geriatr Soc 2020; 68:1755-1762. [PMID: 32246476 PMCID: PMC7497167 DOI: 10.1111/jgs.16427] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/20/2020] [Accepted: 03/05/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Urgency triage in the emergency department (ED) is important for early identification of potentially lethal conditions and extensive resource utilization. However, in older patients, urgency triage systems could be improved by taking geriatric vulnerability into account. We investigated the association of geriatric vulnerability screening in addition to triage urgency levels with 30‐day mortality in older ED patients. DESIGN Secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study. SETTING EDs within four Dutch hospitals. PARTICIPANTS Consecutive patients, aged 70 years or older, who were prospectively included. MEASUREMENTS Patients were triaged using the Manchester Triage System (MTS). In addition, the APOP screener was used as a geriatric screening tool. The primary outcome was 30‐day mortality. Comparison was made between mortality within the geriatric high‐ and low‐risk screened patients in every urgency triage category. We calculated the difference in explained variance of mortality by adding the geriatric screener (APOP) to triage urgency (MTS) by calculating Nagelkerke R2. RESULTS We included 2,608 patients with a median age of 79 (interquartile range = 74‐84) years, of whom 521 (20.0%) patients were categorized as high risk according to geriatric screening. Patients were triaged on urgency as standard (27.2%), urgent (58.5%), and very urgent (14.3%). In total, 132 (5.1%) patients were deceased within a period of 30 days. Within every urgency triage category, 30‐day mortality was threefold higher in geriatric high‐risk compared to low‐risk patients (overall = 11.7% vs 3.4%; P < .001). The explained variance of 30‐day mortality with triage urgency was 1.0% and increased to 6.3% by adding the geriatric screener. CONCLUSION Combining triage urgency with geriatric screening has the potential to improve triage, which may help clinicians to deliver early appropriate care to older ED patients. J Am Geriatr Soc 68:1755‐1762, 2020.
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Affiliation(s)
- Laura C Blomaard
- Department of Internal Medicine, Section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Corianne Speksnijder
- Department of Internal Medicine, Section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jacinta A Lucke
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands.,Department of Emergency Medicine, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Jelle de Gelder
- Department of Internal Medicine, Section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Sander Anten
- Department of Internal Medicine, Section Acute Care, Alrijne Hospital, Leiderdorp, The Netherlands
| | - Stephanie C E Schuit
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.,Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jacobijn Gussekloo
- Department of Internal Medicine, Section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands.,Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Simon P Mooijaart
- Department of Internal Medicine, Section Geriatrics, Leiden University Medical Center, Leiden, The Netherlands.,Institute of Evidence-Based Medicine in Old Age, Leiden, The Netherlands
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Kemp K, Mertanen R, Lääperi M, Niemi-Murola L, Lehtonen L, Castren M. Nonspecific complaints in the emergency department - a systematic review. Scand J Trauma Resusc Emerg Med 2020; 28:6. [PMID: 31992333 PMCID: PMC6986144 DOI: 10.1186/s13049-020-0699-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/05/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Nonspecific complaint (NSC) is a common presenting complaint in the emergency setting, especially in the elderly population. Individual studies have shown that it is associated with significant morbidity and mortality. This prognostic systematic review draws a synthesis of reported outcomes for patients presenting with NSC and compares them with outcomes for patients presenting with a specific complaint. METHODS We conducted a literature search for publications, abstracts and conference presentations from Ovid, Scopus and Web of Science for the past 20 years. Studies were included which treated adult patients presenting to the Emergency Medical Services or Emergency Department with NSC. 2599 studies were screened for eligibility and quality was assessed using the SIGN assessment for bias tool. We excluded any low-quality studies, resulting in nine studies for quantitative analysis. We analysed the included studies for in-hospital mortality, triage category, emergency department length of stay, admission rate, hospital length of stay, intensive care admissions and re-visitation rate and compared outcomes to patients presenting with specific complaints (SC), where data were available. We grouped discharge diagnoses by ICD-10 category. RESULTS We found that patients presenting with NSC were mostly older adults. Mortality for patients with NSC was significantly increased compared to patients presenting with SC [OR 2.50 (95% CI 1.40-4.47)]. They were triaged as urgent less often than SC patients [OR 2.12 (95% CI 1.08-4.16)]. Emergency department length of stay was increased in two out of three studies. Hospital length of stay was increased by 1-3 days. Admission rates were high in most studies, 55 to 84%, and increased in comparison to patients with SC [OR 3.86 (95% CI 1.76-8.47)]. These patients seemed to require more resources than patients with SC. The number for intensive care admissions did not seem to be increased. Data were insufficient to make conclusions regarding re-visitation rates. Discharge diagnoses were spread throughout the ICD-10 main chapters, infections being the most prevalent. CONCLUSIONS Patients with NSC have a high risk of mortality and their care in the Emergency Department requires more time and resources than for patients with SC. We suggest that NSC should be considered a major emergency presentation.
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Affiliation(s)
- Kirsi Kemp
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland.
| | - Reija Mertanen
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
| | - Mitja Lääperi
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
| | - Leila Niemi-Murola
- Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Lasse Lehtonen
- Department of Public Health, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maaret Castren
- Department of Emergency Medicine and Services, Helsinki University Hospital, and Emergency Medicine, Helsinki University, Helsinki, Finland
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Validity of Triage Performed by Nurses Educated by Train-of-Trainer Workshop Participants; a Cross-sectional Study for Assessment of Cascade Training System. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2020; 4:e2. [PMID: 31938771 PMCID: PMC6955037 DOI: 10.22114/ajem.v0i0.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Introduction: In 2010, a national triage train-of-trainer (TOT) workshop was held in Tehran, Iran. Objective: The present study aimed to assess the validity of the triage performed by the nurses educated by those who participated in TOT workshop. Method: This cross-sectional study was carried out in 6 teaching hospitals from 4 universities in Iran. Inter-rater and intra-rater reliability of performed triage by participations was measured. Thirteen nurses were randomly selected. Thereafter, at the end of each working shift, patient data recorded in the daily data registry forms were collected. Then, duration of hospital stay, number of cases admitted to general wards or intensive care units, number of cases discharged from the ED within 12 hours and mortality rate were compared with the triage level determined by the nurse. Results: In total, 30 nurses with a mean age of 28.4 ± 3.7 years were enrolled. In this study, 1491 triage cases (61.6% male) were evaluated, of which 4.2% were triaged as level 1, 18.3% as level 2, 37.1% as level 3, 20.4% as level 4 and 20.0% as level 5. The following outcome was observed: 3.64% were discharged, 6.29% were hospitalized, 3% died and 2.3% were discharged against medical advice without completing treatment. The correlation of determined triage level and patients’ duration of hospitalization was significant based on one-way ANOVA test (p = 0.000). The outcome of the patients significantly correlated with the level of triage determined by the study nurses (p = 0.000). Conclusion: Based on the findings, it appears that triage performed by the study nurses educated by those who participated in TOT workshop through cascade training system had perfect validity.
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Examining the relationship between triage acuity and frailty to inform the care of older emergency department patients: Findings from a large Canadian multisite cohort study. CAN J EMERG MED 2019; 22:74-81. [DOI: 10.1017/cem.2019.432] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
ABSTRACTBackgroundThe 2016 Canadian Triage and Acuity Scale (CTAS) updates introduced frailty screening within triage to more accurately code frail patients who may deteriorate waiting for care. The relationship between triage acuity and frailty is not well understood, but may help inform which supplemental geriatric assessments are beneficial to support care in the emergency department (ED). Our objectives were to investigate the relationship between triage acuity and frailty, and to compare their associations with a series of patient outcomes.MethodsWe conducted a secondary analysis of the Canadian cohort from a multinational prospective study. Data were collected on ED patients 75 years of age and older from eight ED sites across Canada between November 2009 and April 2012. Triage acuity was assigned using the CTAS, whereas frailty was measured using an ED frailty index. Spearman rank and binary logistic regression were used to examine associations.ResultsA total of 2,153 ED patients were analyzed. No association was found between the CTAS and ED frailty index scores assigned to patients (r = .001; p = 0.99). The ED frailty index was associated with hospital admission (odds ratio [OR] = 1.5; 95% confidence interval [CI] = 1.4–1.6), hospital length of stay (OR = 1.4; 95% CI = 1.2–1.6), future hospitalization (OR = 1.1; 95% CI = 1.05–1.2), and ED recidivism (OR = 1.1; 95% CI = 1.04–1.2). The CTAS was associated with hospital admission (e.g., CTAS 2 v. 5; OR = 6; 95% CI = 3.3–11.4).ConclusionOur findings demonstrate that frailty and triage acuity are independent but complementary measures. EDs may benefit from comprehensive frailty screening post-triage, as frailty and its associated geriatric syndromes drive outcomes separate from traditional measures of acuity.
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Al Hasni AK, Al-Rawajfah OM. Effectiveness of Implementing Emergency Severity Index Triage System in a Selected Primary Health Care Center in Oman: A Quasi-Experimental Study. J Emerg Nurs 2019; 45:717.e1-717.e11. [PMID: 31706449 DOI: 10.1016/j.jen.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 11/26/2022]
Abstract
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.
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Are Emergency Departments in the United States Following Recommendations by the Emergency Severity Index to Promote Quality Triage and Reliability? J Emerg Nurs 2019; 45:677-684. [DOI: 10.1016/j.jen.2019.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/05/2019] [Accepted: 05/10/2019] [Indexed: 11/23/2022]
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Malinovska A, Pitasch L, Geigy N, Nickel CH, Bingisser R. Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients. West J Emerg Med 2019; 20:633-640. [PMID: 31316703 PMCID: PMC6625680 DOI: 10.5811/westjem.2019.4.40031] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Revised: 04/05/2019] [Accepted: 04/12/2019] [Indexed: 11/11/2022] Open
Abstract
Introduction Older patients frequently present to the emergency department (ED) with nonspecific complaints (NSC), such as generalized weakness. They are at risk of adverse outcomes, and early risk stratification is crucial. Triage using Emergency Severity Index (ESI) is reliable and valid, but older patients are prone to undertriage, most often at decision point D. The aim of this study was to assess the predictive power of additional clinical parameters in NSC patients. Methods Baseline demographics, vital signs, and deterioration of activity of daily living (ADL) in patients with NSC were prospectively assessed at four EDs. Physicians scored the coherence of history and their first impression. For prediction of 30-day mortality, we combined vital signs at decision point D (heart rate, respiratory rate, oxygen saturation) as “ESI vital,” and added “ADL deterioration,” “incoherence of history,” or “first impression,” using logistic regression models. Results We included 948 patients with a median age of 81 years, 62% of whom were female. The baseline parameters at decision point D (ESI vital) showed an area under the curve (AUC) of 0.64 for predicting 30-day mortality in NSC patients. AUCs increased to 0.67 by adding ADL deterioration to 0.66 by adding incoherence of history, and to 0.71 by adding first impression. Maximal AUC was 0.73, combining all parameters. Conclusion Adding the physicians’ first impressions to vital signs at decision point D increases predictive power of 30-day mortality significantly. Therefore, a modified ESI could improve predictive power of triage in older patients presenting with NSCs.
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Affiliation(s)
| | - Laurentia Pitasch
- University Hospital Basel, Department of Emergency Medicine, Basel, Switzerland
| | - Nicolas Geigy
- Liestal Cantonal Hospital, Department of Emergency Medicine, Liestal, Switzerland
| | - Christian H Nickel
- University Hospital Basel, Department of Emergency Medicine, Basel, Switzerland
| | - Roland Bingisser
- University Hospital Basel, Department of Emergency Medicine, Basel, Switzerland
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Development and validation of the Heidelberg Neurological Triage System (HEINTS). J Neurol 2019; 266:2685-2698. [PMID: 31321517 DOI: 10.1007/s00415-019-09472-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 07/10/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND/OBJECTIVE Neurological syndromes are underrepresented in existing triage systems which are not validated for neurological patients; therefore, we developed and validated the new Heidelberg Neurological Triage System (HEINTS) in a prospective, single-center observational study. METHODS Patients were triaged according to the new triage system by nurses and physicians (stage 1) as well as trained nurses (stage 2). In stage 1, all patients presenting to the neurological emergency room (ER) were triaged by nurses and physicians. In stage 2, three specially trained nurses triaged patients according to HEINTS. The main outcomes comprised interrater agreement between nurses' and physicians' triage (stage 1), sensitivity and specificity to detect emergencies (stages 1 and 2), and improvement in triage quality as a result of training (stage 2), as well as correlation of HEINTS with hospital admissions and resource utilization. RESULTS In stage 1 (n = 2423 patients), sensitivity and specificity to detect neurological emergencies were 84.2% (SD 0.8%) and 85.4% (SD 0.8%) for nurses, as well as 92.4% (SD 0.6%) and 84.1% (SD 0.9%) for physicians, respectively. The interrater-reliability between nurses and physicians in stage 1 was moderate [Cohen's kappa 0.44, standard deviation (SD) 0.02]. In stage 2 (n = 506 patients), sensitivity of trained nurses increased to 94.3% (SD 1.0%), while specificity decreased to 74.8% (SD 1.9%). Correlation of HEINTS triage with hospital admission and resource utilization in both stages was highly significant. CONCLUSIONS HEINTS predicted hospital admissions and resource utilization. Agreement between nurses and physicians was moderate. HEINTS, applied by physicians and by nurses after training, reliably detected neurological emergencies.
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Malinovska A, Pitasch L, Geigy N, Nickel C, Bingisser R. Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients. West J Emerg Med 2019. [DOI: 10.5811//westjem.2019.4.40031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
| | - Laurentia Pitasch
- University Hospital Basel, Department of Emergency Medicine, Basel, Switzerland
| | - Nicolas Geigy
- Liestal Cantonal Hospital, Department of Emergency Medicine, Liestal, Switzerland
| | - Christian Nickel
- University Hospital Basel, Department of Emergency Medicine, Basel, Switzerland
| | - Roland Bingisser
- University Hospital Basel, Department of Emergency Medicine, Basel, Switzerland
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Kuriyama A, Ikegami T, Nakayama T. Impact of age on the discriminative ability of an emergency triage system: A cohort study. Acta Anaesthesiol Scand 2019; 63:781-788. [PMID: 30888059 DOI: 10.1111/aas.13342] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 01/06/2019] [Accepted: 01/25/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Emergency triage systems optimize resources in emergency departments (EDs) for those who need urgent care. Five-level triage systems, such as the Canadian Triage and Acuity Scale (CTAS), have been used worldwide. We examined whether the discriminative ability of an emergency triage system varies according to age group using a patient cohort triaged with the Japan Triage and Acuity Scale (JTAS), a validated system based on the CTAS. METHODS We conducted a cohort study of 27 120 self-presenting patients aged 16 years and older who were triaged with (JTAS) between June 2013 and May 2014 at a Japanese tertiary care hospital. Outcome measures were admission to intensive care units (ICUs) as the primary and in-hospital death as the secondary. We described the trends of the discriminative ability of JTAS using areas under the curve of the receiver operating characteristic (AUROC), sensitivity, specificity, positive predictive value, and negative predictive value of JTAS for seven age categories. RESULTS The AUROC of JTAS for ICU admission decreased with age (maximum 0.85 to minimum 0.71), sensitivity non-significantly decreased (maximum 0.67 to minimum 0.32), and specificity declined with age (maximum 0.96 to minimum 0.88). The positive and negative predictive value increased (minimum 0.03 to maximum 0.09) and decreased (minimum 0.98 to maximum 0.99), respectively, with age. Overall misclassification increased across age groups (P < 0.001). This trend was mostly consistent with the analysis of in-hospital death. CONCLUSION Our study suggests that the discriminative ability of an emergency triage system decreases as patient age increases, corresponding to a decrease in specificity. Undertriage may not significantly increase, but misclassification significantly increases as patient age increases.
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Affiliation(s)
- Akira Kuriyama
- Emergency and Critical Care Center Kurashiki Central Hospital Okayama Japan
- Department of Health Informatics Kyoto University Graduate School of Medicine and Public Health Kyoto Japan
| | - Tetsunori Ikegami
- Emergency and Critical Care Center Kurashiki Central Hospital Okayama Japan
| | - Takeo Nakayama
- Department of Health Informatics Kyoto University Graduate School of Medicine and Public Health Kyoto Japan
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["Triage"-primary assessment of patients in the emergency department : An overview with a systematic review]. Med Klin Intensivmed Notfmed 2019; 115:668-681. [PMID: 31197419 DOI: 10.1007/s00063-019-0589-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Revised: 04/19/2019] [Accepted: 05/12/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND "Triage" means the primary assessment of a previously unknown patient with an acute health disorder, initially considered a medical emergency. The initial triage is part of the primary assessment, which also includes the registration of administrative data and patient's mode of arrival. OBJECTIVES The aim of the work is to provide an overview of frequently used structured primary assessment tools and the underlying evidence for their use in the emergency room. METHODS Based on a systematic literature search in PubMed, 41 articles were selected according to predefined criteria. RESULTS The most frequently used primary assessment systems in Germany are the Emergency Severity Index (ESI) and the Manchester Triage System (MTS). Scientific evidence exists for the accuracy and reliability of the primary assessment with these instruments. However, there are no gold standards for measuring urgency, so that separate criteria must be defined. Sufficient data to determine a treatment sector or the necessary staffing levels are lacking. CONCLUSIONS Structured primary assessment using formalized systems alone is inadequate to categorize the urgency of emergency and acute patients. In fact, a combination of different measures in an interprofessional team is required. Primary assessment systems and processes generally do not allow patients to be referred to downstream structures without a thorough medical examination.
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Gräff I, Latzel B, Glien P, Fimmers R, Dolscheid-Pommerich RC. Validity of the Manchester Triage System in emergency patients receiving life-saving intervention or acute medical treatment-A prospective observational study in the emergency department. J Eval Clin Pract 2019; 25:398-403. [PMID: 30216602 DOI: 10.1111/jep.13030] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 08/11/2018] [Accepted: 08/13/2018] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS, AND OBJECTIVES The spectrum of cases seen by emergency departments ranges from minor illnesses or injuries to complex diseases with high mortality. Some patients require life-saving interventions (LSIs) or therapeutic treatment for an acute illness to prevent an expected imminent life-threatening condition immediately upon arrival. No published study has evaluated the validity of the Manchester Triage System (MTS) in the context of immediate LSI or acute emergency treatment (AET). METHODS The definition of LSI was based on a literature search. AET was defined by an expert panel based on current emergency guidelines and diagnostic guideline recommendations. In a 4-month observation period, an independent external observer documented all executed LSIs or AETs using a checklist. Sensitivity, negative predictive value, likelihood ratio negative (LR-), and accuracy of MTS triage level for the identification of patients receiving an LSI or AET were calculated. RESULTS In 1762 patients, 40 (2.3%) LSIs and 89 (5.1%) AETs were observed. In the LSI group, sensitivity of MTS was 75.0%, negative predictive value (NPV) was 99.2% (95% CI: 98.7%-99.6%), LR- was 0.303 (95% CI: 0.189-0.487) and accuracy (ACC) was 98.5% (95% CI: 97.8%-98.9%). In the AET group, sensitivity was 82.0%, NPV was 98.9% (95% CI: 98.1%-99.3%), LR- was 0.206 (95% CI: 0.132-0.322), and ACC was 86.5% (95% CI: 84.9%-88.1%). CONCLUSION The MTS is a valid instrument for a first assessment of emergency patients in critical condition upon arrival.
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Affiliation(s)
- Ingo Gräff
- Emergency Department, University Hospital Bonn, Bonn, Germany
| | - Benjamin Latzel
- Emergency Department, University Hospital Bonn, Bonn, Germany
| | - Procula Glien
- Emergency Department, University Hospital Bonn, Bonn, Germany
| | - Rolf Fimmers
- Institute for Medical Biometry, Informatics and Epidemiology, University Hospital Bonn, Bonn, Germany
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Schultz M, Rasmussen LJH, Carlson N, Hasselbalch RB, Jensen BN, Usinger L, Eugen-Olsen J, Torp-Pedersen C, Rasmussen LS, Iversen KK. Risk assessment models for potential use in the emergency department have lower predictive ability in older patients compared to the middle-aged for short-term mortality - a retrospective cohort study. BMC Geriatr 2019; 19:134. [PMID: 31096925 PMCID: PMC6521424 DOI: 10.1186/s12877-019-1154-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 05/09/2019] [Indexed: 11/29/2022] Open
Abstract
Background Older patients is a complex group at increased risk of adverse outcomes compared to younger patients, which should be considered in the risk assessment performed in emergency departments. We evaluated whether the predictive ability of different risk assessment models for acutely admitted patients is affected by age. Methods Cohort study of middle-aged and older patients. We investigated the accuracy in discriminating between survivors and non-survivors within 7 days of different risk assessment models; a traditional triage algorithm, a triage algorithm with clinical assessment, vital signs, routine biomarkers, and the prognostic biomarker soluble urokinase plasminogen activator receptor (suPAR). Results The cohort included 22,653 (53.2%) middle-aged patients (age 40–69 years), and 19,889 (46.8%) older patients (aged 70+ years). Death within 7 days occurred in 139 patients (0.6%) in middle-aged patients and 596 (3.0%) of the older patients. The models based on vital signs and routine biomarkers had the highest area under the curve (AUC), and both were significantly better at discriminating 7-day mortality in middle-aged patients compared to older patients; AUC (95% CI): 0.88 (0.84–0.91), 0.75 (0.72–0.78), P < 0.01, and 0.86 (0.82–0.90), 0.76 (0.73–0.78), P < 0.001. In a subgroup of the total cohort (6.400 patients, 15.0%), the suPAR level was available. suPAR had the highest AUC of all individual predictors with no significant difference between the age groups, but further research in this biomarker is required before it can be used. Conclusion The predictive value was lower in older patients compared to middle-aged patients for all investigated models. Vital signs or routine biomarkers constituted the best models for predicting 7-day mortality and were better than the traditional triage model. Hence, the current risk assessment for short-term mortality can be strengthened, but modifications for age should be considered when constructing new risk assessment models in the emergency department. Electronic supplementary material The online version of this article (10.1186/s12877-019-1154-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Martin Schultz
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730, Herlev, Denmark. .,Department of Internal Medicine and Geriatrics, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark.
| | | | | | - Rasmus Bo Hasselbalch
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730, Herlev, Denmark
| | - Birgitte Nybo Jensen
- Department of Emergency Medicine, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Lotte Usinger
- Department of Internal Medicine and Geriatrics, Herlev and Gentofte Hospital, University of Copenhagen, Herlev, Denmark
| | - Jesper Eugen-Olsen
- Clinical Research Centre, Amager and Hvidovre Hospital, University of Copenhagen, Hvidovre, Denmark
| | - Christian Torp-Pedersen
- Department of Health, Science and Technology, Aalborg University Hospital, Aalborg, Denmark.,Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Cardiology, Herlev and Gentofte Hospital, University of Copenhagen, Herlev Ringvej 75, DK-2730, Herlev, Denmark
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Do physicians and nurses agree on triage levels in the emergency department? A meta-analysis. Notf Rett Med 2019. [DOI: 10.1007/s10049-019-0580-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Kuriyama A, Kaihara T, Ikegami T. Validity of the Japan Acuity and Triage Scale in elderly patients: A cohort study. Am J Emerg Med 2019; 37:2159-2164. [PMID: 30876775 DOI: 10.1016/j.ajem.2019.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 02/26/2019] [Accepted: 03/07/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND In developed nations, the age of patients in emergency departments (ED) continues to increase. Many emergency triage systems, such as the Canadian Triage and Acuity Scale (CTAS), triage patients as a homogenous group, regardless of age. However, older adults have multiple comorbidities and a higher risk of undertriage. The Japan Acuity and Triage Scale (JTAS) was developed based on the CTAS and has been validated for overall adults. We assessed the validity of the JTAS for use in elderly ED patients. METHODS This was a secondary analysis of a cohort study that previously validated the JTAS in self-presenting adults of all ages in the ED of a Japanese tertiary-care hospital. We included non-transferred patients who were ≥65 years old and triaged between June 2013 and May 2014. Our primary outcome measures were overall admission and ED length of stay. Our secondary outcomes included admission to the intensive care units (ICUs) and in-hospital mortality. We examined the association between the triage level and patient outcomes with multivariable logistic regression analysis (overall and ICU admission and in-hospital mortality) and the Kruskal-Wallis rank-sum test (ED length of stay). RESULTS We included a total of 11,087 elderly patients in our study. Higher odds ratios for overall and ICU admission and in-hospital mortality corresponded to higher acuity levels. ED length of stay was significantly longer in patients with a higher JTAS level (p < 0.001). Twenty-nine percent of admissions who were triaged as lower acuity levels were related to non-acute diseases including malignancy-related events. CONCLUSION Our study suggests an association between the JTAS triage level and clinical outcomes in self-presenting elderly patients, thereby demonstrating the validity of the JTAS in these patients. However, admission due to chronic diseases including malignancy was common in patients who were rated as low acuity level.
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Affiliation(s)
- Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan.
| | - Toshie Kaihara
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan
| | - Tetsunori Ikegami
- Emergency and Critical Care Center, Kurashiki Central Hospital, Japan
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Platts-Mills TF, Staudenmayer K. The Applied Mathematics of the Geriatric Trauma Evaluation. Ann Emerg Med 2019; 73:291-293. [PMID: 30797294 DOI: 10.1016/j.annemergmed.2019.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Indexed: 11/26/2022]
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