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Ferri P, Lomonaco V, Passaro LC, Félix-De Castro A, Sánchez-Cuesta P, Sáez C, García-Gómez JM. Deep continual learning for medical call incidents text classification under the presence of dataset shifts. Comput Biol Med 2024; 175:108548. [PMID: 38718666 DOI: 10.1016/j.compbiomed.2024.108548] [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: 09/08/2023] [Revised: 04/11/2024] [Accepted: 04/28/2024] [Indexed: 05/15/2024]
Abstract
The aim of this work is to develop and evaluate a deep classifier that can effectively prioritize Emergency Medical Call Incidents (EMCI) according to their life-threatening level under the presence of dataset shifts. We utilized a dataset consisting of 1982746 independent EMCI instances obtained from the Health Services Department of the Region of Valencia (Spain), with a time span from 2009 to 2019 (excluding 2013). The dataset includes free text dispatcher observations recorded during the call, as well as a binary variable indicating whether the event was life-threatening. To evaluate the presence of dataset shifts, we examined prior probability shifts, covariate shifts, and concept shifts. Subsequently, we designed and implemented four deep Continual Learning (CL) strategies-cumulative learning, continual fine-tuning, experience replay, and synaptic intelligence-alongside three deep CL baselines-joint training, static approach, and single fine-tuning-based on DistilBERT models. Our results demonstrated evidence of prior probability shifts, covariate shifts, and concept shifts in the data. Applying CL techniques had a statistically significant (α=0.05) positive impact on both backward and forward knowledge transfer, as measured by the F1-score, compared to non-continual approaches. We can argue that the utilization of CL techniques in the context of EMCI is effective in adapting deep learning classifiers to changes in data distributions, thereby maintaining the stability of model performance over time. To our knowledge, this study represents the first exploration of a CL approach using real EMCI data.
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Affiliation(s)
- Pablo Ferri
- Biomedical Data Science Laboratory (BDSLab), Instituto de Aplicaciones de las Tecnologías de la Información y de las Comunicaciones Avanzadas (ITACA), Universitat Politècnica de València (UPV), Valencia, Spain.
| | - Vincenzo Lomonaco
- Department of Computer Science, University of Pisa (Unipi), Pisa, Italy.
| | - Lucia C Passaro
- Department of Computer Science, University of Pisa (Unipi), Pisa, Italy.
| | - Antonio Félix-De Castro
- Conselleria de Sanitat Universal i Salut Pública, Generalitat Valenciana (GVA), Valencia, Spain.
| | | | - Carlos Sáez
- Biomedical Data Science Laboratory (BDSLab), Instituto de Aplicaciones de las Tecnologías de la Información y de las Comunicaciones Avanzadas (ITACA), Universitat Politècnica de València (UPV), Valencia, Spain.
| | - Juan M García-Gómez
- Biomedical Data Science Laboratory (BDSLab), Instituto de Aplicaciones de las Tecnologías de la Información y de las Comunicaciones Avanzadas (ITACA), Universitat Politècnica de València (UPV), Valencia, Spain.
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Ingielewicz A, Rychlik P, Sieminski M. Drinking from the Holy Grail-Does a Perfect Triage System Exist? And Where to Look for It? J Pers Med 2024; 14:590. [PMID: 38929811 PMCID: PMC11204574 DOI: 10.3390/jpm14060590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/28/2024] Open
Abstract
The Emergency Department (ED) is a facility meant to treat patients in need of medical assistance. The choice of triage system hugely impactsed the organization of any given ED and it is important to analyze them for their effectiveness. The goal of this review is to briefly describe selected triage systems in an attempt to find the perfect one. Papers published in PubMed from 1990 to 2022 were reviewed. The following terms were used for comparison: "ED" and "triage system". The papers contained data on the design and function of the triage system, its validation, and its performance. After studies comparing the distinct means of patient selection were reviewed, they were meant to be classified as either flawed or non-ideal. The validity of all the comparable segregation systems was similar. A possible solution would be to search for a new, measurable parameter for a more accurate risk estimation, which could be a game changer in terms of triage assessment. The dynamic development of artificial intelligence (AI) technologies has recently been observed. The authors of this study believe that the future segregation system should be a combination of the experience and intuition of trained healthcare professionals and modern technology (artificial intelligence).
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Affiliation(s)
- Anna Ingielewicz
- Department of Emergency Medicine, Faculty of Health Science, Medical University of Gdansk, Mariana Smoluchowskiego Street 17, 80-214 Gdansk, Poland;
- Emergency Department, Copernicus Hospital, Nowe Ogrody Street 1-6, 80-203 Gdansk, Poland
| | - Piotr Rychlik
- Emergency Department, Copernicus Hospital, Nowe Ogrody Street 1-6, 80-203 Gdansk, Poland
| | - Mariusz Sieminski
- Department of Emergency Medicine, Faculty of Health Science, Medical University of Gdansk, Mariana Smoluchowskiego Street 17, 80-214 Gdansk, Poland;
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Bienzeisler J, Becker G, Erdmann B, Kombeiz A, Majeed RW, Röhrig R, Greiner F, Otto R, Otto-Sobotka F. The Effects of Displaying the Time Targets of the Manchester Triage System to Emergency Department Personnel: Prospective Crossover Study. J Med Internet Res 2024; 26:e45593. [PMID: 38743464 PMCID: PMC11134237 DOI: 10.2196/45593] [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: 01/09/2023] [Revised: 02/02/2024] [Accepted: 03/31/2024] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND The use of triage systems such as the Manchester Triage System (MTS) is a standard procedure to determine the sequence of treatment in emergency departments (EDs). When using the MTS, time targets for treatment are determined. These are commonly displayed in the ED information system (EDIS) to ED staff. Using measurements as targets has been associated with a decline in meeting those targets. OBJECTIVE This study investigated the impact of displaying time targets for treatment to physicians on processing times in the ED. METHODS We analyzed the effects of displaying time targets to ED staff on waiting times in a prospective crossover study, during the introduction of a new EDIS in a large regional hospital in Germany. The old information system version used a module that showed the time target determined by the MTS, while the new system version used a priority list instead. Evaluation was based on 35,167 routinely collected electronic health records from the preintervention period and 10,655 records from the postintervention period. Electronic health records were extracted from the EDIS, and data were analyzed using descriptive statistics and generalized additive models. We evaluated the effects of the intervention on waiting times and the odds of achieving timely treatment according to the time targets set by the MTS. RESULTS The average ED length of stay and waiting times increased when the EDIS that did not display time targets was used (average time from admission to treatment: preintervention phase=median 15, IQR 6-39 min; postintervention phase=median 11, IQR 5-23 min). However, severe cases with high acuity (as indicated by the triage score) benefited from lower waiting times (0.15 times as high as in the preintervention period for MTS1, only 0.49 as high for MTS2). Furthermore, these patients were less likely to receive delayed treatment, and we observed reduced odds of late treatment when crowding occurred. CONCLUSIONS Our results suggest that it is beneficial to use a priority list instead of displaying time targets to ED personnel. These time targets may lead to false incentives. Our work highlights that working better is not the same as working faster.
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Affiliation(s)
- Jonas Bienzeisler
- Institute of Medical Informatics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | | | | | - Alexander Kombeiz
- Institute of Medical Informatics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Raphael W Majeed
- Institute of Medical Informatics, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Department of Internal Medicine, Universities of Giessen and Marburg Lung Center (UGMLC), German Center for Lung Research (DZL), Giessen, Germany
| | - Rainer Röhrig
- Institute of Medical Informatics, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Felix Greiner
- Institute for Occupational and Maritime Medicine (ZfAM), University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
- Department of Trauma Surgery, Otto von Guericke University, Magdeburg, Germany
| | - Ronny Otto
- Department of Trauma Surgery, Otto von Guericke University, Magdeburg, Germany
| | - Fabian Otto-Sobotka
- Division of Epidemiology and Biometry, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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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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Mollet A, Rousselet L, Tristram D, Kalach N, Pelzer MM, Charkaluk ML, Delebarre M. Comparison between local and three validated triage systems in an emergency department for 2126 children under 3 months. Acta Paediatr 2023; 112:1986-1994. [PMID: 37222311 DOI: 10.1111/apa.16858] [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: 02/28/2023] [Revised: 05/17/2023] [Accepted: 05/23/2023] [Indexed: 05/25/2023]
Abstract
AIM Triage of patients less than 3 months old was not already studied. The aim was to evaluate Paediatric Emergency Department triage in patients less than 3 months old and newborns using a local system in comparison with three validated paediatric triage systems (Canadian Triage and Acuity Scale, Manchester Triage System and Emergency Severity Index) and to determine inter-system agreement. METHODS All admissions of patients less than 3 months old admitted to the Emergency Department of the Saint Vincent University Hospital between April 2018 and December 2019 were included. The local triage system level was determined prospectively for comparison with retrospectively calculated triage levels of the validated systems. Hospitalisation rates were compared and inter-system agreements determined. RESULTS Among emergency admissions, 2126 were included (55% males, mean age 45 days). Hospitalisation rate increased with priority severity as determined by all triage systems studied. Cohen's kappa showed slight agreement between the local triage system and the Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System (weighted kappa = 0.133, 0.185 and 0.157 respectively). CONCLUSION Whether prospective or retrospective triage used, the systems studied exhibited good association with hospitalisation rate for patients aged less than 3 months and newborn infants.
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Affiliation(s)
- Agathe Mollet
- Lille Catholic hospitals, Paediatric Department, Lille Catholic University, Lille, France
| | - Louis Rousselet
- Lille Catholic hospitals, Medical Information Department, Lille Catholic University, Lille, France
| | - Domitille Tristram
- Lille Catholic hospitals, Research Department, Lille Catholic University, Lille, France
| | - Nicolas Kalach
- Lille Catholic hospitals, Paediatric Department, Lille Catholic University, Lille, France
| | - Marie Moukagni Pelzer
- Lille Catholic hospitals, Paediatric Department, Lille Catholic University, Lille, France
| | - Marie-Laure Charkaluk
- Lille Catholic hospitals, Neonatology Department, Lille Catholic University, Lille, France
| | - Mathilde Delebarre
- Lille Catholic hospitals, Paediatric Department, Lille Catholic University, Lille, France
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Zaboli A, Ausserhofer D, Sibilio S, Toccolini E, Paulmichl R, Giudiceandrea A, Bonora A, Pfeifer N, Turcato G. Electrocardiogram interpretation during nurse triage improves the performance of the triage system in patients with cardiovascular symptoms - A prospective observational study. Int Emerg Nurs 2023; 68:101273. [PMID: 36924577 DOI: 10.1016/j.ienj.2023.101273] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/13/2023] [Accepted: 02/15/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND An immediate ECG on arrival of a patient with cardiovascular symptoms in the ED may anticipate the need for life-saving intervention. The aim was to evaluate whether ECG interpretation during nurse triage can improve triage system performance in patients with cardiovascular symptoms. METHODS All patients who required an assessment for cardiovascular symptoms were considered for this observational study. During triage assessment, the nurses assessed the patient's level of urgency applying the MTS, then again after this evaluation (confirming or modifying the level of urgency based on personal clinical experience) and after interpretation of the patient's ECG. The main study outcome was the diagnosis of an acute cardiovascular event. RESULTS Of the 1211 patients in the study, 10.5% presented the main study outcome. ECG interpretation in triage exhibited a nurse-physician agreement of 92.9% (p<0.001). increased patient priority in 7.5% of cases and reduced it in 39.6%. The discriminatory ability of the triage system had an area under the ROC of 0.712and 0.845 after ECG interpretation. ECG interpretation improved the baseline assessment of priority, with an NRI of 60.1% (p<0.001). CONCLUSIONS ECG interpretation in triage can be a simple and safe tool that improves the assessment of patient priority.
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Affiliation(s)
- Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy.
| | - Dietmar Ausserhofer
- College of Health Care Professions Claudiana, Bolzano-Bozen, Italy; Institute of Nursing Science, Department of Public Health, University of Basel, Switzerland
| | - Serena Sibilio
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Elia Toccolini
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Rupert Paulmichl
- Department of Cardiology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | | | - Antonio Bonora
- Emergency Department, University of Verona, Verona, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
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Reliability and Validity of a New Computer-Based Triage Decision Support Tool: ANKUTRIAGE. Disaster Med Public Health Prep 2022; 17:e162. [PMID: 35765149 DOI: 10.1017/dmp.2022.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Triage is a tool used to determine patients' severity of illness or injury within minutes of arrival. This study aims to assess the reliability and validity of a new computer-based triage decision support tool, ANKUTRIAGE, prospectively. METHODS ANKUTRIAGE, a 5-level triage tool was established considering 2 major factors, patient's vital signs and characteristics of the admission complaint. Adult patients admitted to the ED between July and October, 2019 were consecutively and independently double triaged by 2 assessors using ANKUTRIAGE system. To measure inter-rater reliability, quadratic-weighted kappa coefficients (Kw) were calculated. For the validity, associations among urgency levels, resource use, and clinical outcomes were evaluated. RESULTS The inter-rater reliability between users of ANKUTRIAGE was excellent with an agreement coefficient (Kw) greater than 0.8 in all compared groups. In the validity phase, hospitalization rate, intensive care unit admission and mortality rate decreased from level 1 to 5. Likewise, according to the urgency levels, resource use decreased significantly as the triage level decreased (P < 0.05). CONCLUSIONS ANKUTRIAGE proved to be a valid and reliable tool in the emergency department. The results showed that displaying the key discriminator for each complaint to assist decision leads to a high inter-rater agreement with good correlation between urgency levels and clinical outcomes, as well as between urgency levels and resource consumptions.
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Beane A, Wijesiriwardana W, Pell C, Dullewe NP, Sujeewa JA, Rathnayake RMD, Jayasinghe S, Dondorp AM, Schultsz C, Haniffa R. Recognising the deterioration of patients in acute care wards: a qualitative study. Wellcome Open Res 2022; 7:137. [PMID: 37601318 PMCID: PMC10435917 DOI: 10.12688/wellcomeopenres.17624.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2022] [Indexed: 08/22/2023] Open
Abstract
Background: Infrastructure, equipment and staff constraints are often cited as barriers to the recognition and rescue of deteriorating patients in resource-limited settings. The impact of health-system organisation, decision-making and organisational culture on recognition of deterioration is however poorly understood. This study explores how health care providers recognise deterioration of patients in acute care in Sri Lanka. Methods: In-depth interviews exploring decision making and care processes related to recognition of deterioration, were conducted with a purposive sample of 23 health care workers recruited from ten wards at a district hospital in Sri Lanka. Interviews were audio-recorded, transcribed and coded thematically, line-by-line, using a general inductive approach. Results: A legacy of initial assessment on admission and inimical organisational culture undermined recognition of deteriorating patients in hospital. Informal triaging at the time of ward admission resulted in patients presenting with red-flag diagnoses and vital sign derangement requiring resuscitation being categorised as "bad". The legacy of this categorisation was a series of decision-making biases anchored in the initial assessment, which remained with the patient throughout their stay. Management for patients categorised as "bad" was prioritised by healthcare workers coupled with a sense of fatalism regarding adverse outcomes. Health care workers were reluctant to deviate from the original plan of care despite changes in patient condition (continuation bias). Organisational culture - vertical hierarchy, siloed working and a reluctance to accept responsibility- resulted in omissions which undermined recognition of deterioration. Fear of blame was a barrier to learning from adverse events. Conclusions: The legacy of admission assessment and hospital organisational culture undermined recognition of deterioration. Opportunities for improving recognition of deterioration in this setting may include establishing formal triage and medical emergency teams to facilitate timely recognition and escalation.
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Affiliation(s)
- Abi Beane
- Nat-Intensive Care Surveillance, MORU, Colombo, 08, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7BN, UK
- Academic Medical Centre, University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
| | | | - Christopher Pell
- Academic Medical Centre, University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, 105 BP, The Netherlands
| | - N. P. Dullewe
- Nat-Intensive Care Surveillance, MORU, Colombo, 08, Sri Lanka
| | - J. A. Sujeewa
- Monaragala District General Hospital, Monaragala, Sri Lanka
| | | | - Saroj Jayasinghe
- Department of Medical Humanities, University of Colombo, Colombo, 8, Sri Lanka
| | - Arjen M. Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7BN, UK
| | - Constance Schultsz
- Academic Medical Centre, University of Amsterdam, Amsterdam, 1105 AZ, The Netherlands
- Amsterdam Institute for Global Health and Development (AIGHD), Amsterdam, 105 BP, The Netherlands
| | - Rashan Haniffa
- Nat-Intensive Care Surveillance, MORU, Colombo, 08, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, 10400, Thailand
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Singh S, Awasthi S. Effect of In-Situation Versus Manchester Triage System-Based Initial Case Management on Hospital-Based Mortality: A Before and After Study. Indian J Pediatr 2022; 89:553-557. [PMID: 35275337 DOI: 10.1007/s12098-022-04092-5] [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: 04/11/2021] [Accepted: 10/25/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To compare mortality and treatment-initiation time pre- and post introduction of Manchester Triage System (MTS) in patients of age group 1 mo to 15 y admitted in a tertiary care hospital in India. METHODS Pre- and post intervention study conducted on a prospective cohort of patients hospitalized over a period of 6 mo, who were triaged using MTS and compared with a retrospective cohort, who were not formally triaged using any system and were admitted to the hospital during the past 6 mo, prior to commencement of the study. Intervention was training of resident doctors for five MTS urgencies using flowcharts and discriminators and displaying them in the emergency room. Data on clinical and outcome variables were abstracted from hospital case record sheets in both the cohorts. RESULTS The present study was conducted from May 2019 to April 2020 including 450 patients hospitalized from August 2019 to January 2020 in a prospective cohort and a retrospective cohort of 450 patients hospitalized from January 2019 to June 2019. Overall mortality in pre-MTS group was 26.2% (118/450) as compared to 20.9% (94/450) in post-MTS group (p value = 0.021). Average treatment time was reduced from 30 to 10 min after implementation of MTS (p value = 0.001). CONCLUSION Implementation of MTS in pediatric emergency leads to statistically significant reduction of mortality and average treatment-initiation time.
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Affiliation(s)
- Sweta Singh
- Department of Pediatrics, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India
| | - Shally Awasthi
- Department of Pediatrics, King George's Medical University, Lucknow, Uttar Pradesh, 226003, India.
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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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Kongensgaard FT, Fløjstrup M, Lassen A, Dahlin J, Brabrand M. Are 5-level triage systems improved by using a symptom based approach?-a Danish cohort study. Scand J Trauma Resusc Emerg Med 2022; 30:31. [PMID: 35468799 PMCID: PMC9036764 DOI: 10.1186/s13049-022-01016-2] [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: 12/19/2021] [Accepted: 04/08/2022] [Indexed: 11/18/2022] Open
Abstract
Background Five-level triage systems are being utilized in Danish emergency departments with and without the use of presenting symptoms. The aim of this study was to validate and compare two 5-level triage systems used in Danish emergency departments: “Danish Emergency Process Triage” (DEPT) based on a combination of vital signs and presenting symptoms and a locally adapted version of DEPT (VITAL-TRIAGE) using vital signs only.
Methods This was a retrospective cohort using data from five Danish emergency departments. All patients attending an emergency department during the period of 1 April 2012 until 31 December 2015 were included. Validity of the two triage systems was assessed by comparing urgency categories determined by each triage system with critical outcomes: admission to Intensive care unit (ICU) within 24 h, 2-day mortality, diagnosis of critical illness, surgery within 48 h, discharge within 4 h and length of hospital stay.
Results We included 632,196 ED contacts. Sensitivity for 24-h ICU admission was 0.79 (95% confidence interval 0.78–0.80) for DEPT and 0.44 (0.41–0.47) for VITAL-TRIAGE. The sensitivity for 2-day mortality was 0.69 (0.67–0.70) for DEPT and 0.37 (0.34–0.41) for VITAL-TRIAGE. The sensitivity to detect diagnoses of critical illness was 0.48 (0.47–0.50) for DEPT and 0.09 (0.08–0.10) for VITAL-TRIAGE. The sensitivity for predicting surgery within 48 h was 0.30 (0.30–0.31) in DEPT and 0.04 (0.04–0.04) in VITAL-TRIAGE. Length of stay was longer in VITAL-TRIAGE than DEPT. The sensitivity of DEPT to predict patients discharged within 4 h was 0.91 (0.91–0.92) while VITAL-TRIAGE was higher at 0.99 (0.99–0.99). The odds ratio for 24-h ICU admission and 2-day mortality was increased in high-urgency categories of both triage systems compared to low-urgency categories.
Conclusions High urgency categories in both triage systems are correlated with adverse outcomes. The inclusion of presenting symptoms in a modern 5-level triage system led to significantly higher sensitivity measures for the ability to predict outcomes related to patient urgency. DEPT achieves equal prognostic performance as other widespread 5-level triage systems.
Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01016-2.
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Affiliation(s)
| | - Marianne Fløjstrup
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark
| | - Annmarie Lassen
- Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Jan Dahlin
- Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
| | - Mikkel Brabrand
- Department of Emergency Medicine, Hospital of South West Jutland, Esbjerg, Denmark.,Department of Regional Health Research, University of Southern Denmark, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark.,Department of Emergency Medicine, Odense University Hospital, Odense, Denmark
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Beane A, Wijesiriwardana W, Pell C, Dullewe NP, Sujeewa JA, Rathnayake RMD, Jayasinghe S, Dondorp AM, Schultsz C, Haniffa R. Recognising the deterioration of patients in acute care wards: a qualitative study. Wellcome Open Res 2022. [DOI: 10.12688/wellcomeopenres.17624.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Infrastructure, equipment and staff constraints are often cited as barriers to the recognition and rescue of deteriorating patients in resource-limited settings. The impact of health-system organisation, decision-making and organisational culture on recognition of deterioration is however poorly understood. This study explores how health care providers recognise deterioration of patients in acute care in Sri Lanka. Methods: In-depth interviews exploring decision making and care processes related to recognition of deterioration, were conducted with a purposive sample of 23 health care workers recruited from ten wards at a district hospital in Sri Lanka. Interviews were audio-recorded, transcribed and coded thematically, line-by-line, using a general inductive approach. Results: A legacy of initial assessment on admission and inimical organisational culture undermined recognition of deteriorating patients in hospital. Informal triaging at the time of ward admission resulted in patients presenting with red-flag diagnoses and vital sign derangement requiring resuscitation being categorised as "bad". The legacy of this categorisation was a series of decision-making biases anchored in the initial assessment, which remained with the patient throughout their stay. Management for patients categorised as “bad” was prioritised by healthcare workers coupled with a sense of fatalism regarding adverse outcomes. Health care workers were reluctant to deviate from the original plan of care despite changes in patient condition (continuation bias). Organisational culture - vertical hierarchy, siloed working and a reluctance to accept responsibility- resulted in omissions which undermined recognition of deterioration. Fear of blame was a barrier to learning from adverse events. Conclusions: The legacy of admission assessment and hospital organisational culture undermined recognition of deterioration. Opportunities for improving recognition of deterioration in this setting may include establishing formal triage and medical emergency teams to facilitate timely recognition and escalation.
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Wallstab F, Greiner F, Schirrmeister W, Wehrle M, Walcher F, Wrede C, Habbinga K, Behringer W, Brammen D. German emergency department measures in 2018: a status quo based on the Utstein reporting standard. BMC Emerg Med 2022; 22:5. [PMID: 35016633 PMCID: PMC8753932 DOI: 10.1186/s12873-021-00563-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/13/2021] [Indexed: 12/03/2022] Open
Abstract
Background Compelling data on clinical emergency medicine is required for healthcare system management. The aim of this survey was to describe the nationwide status quo of emergency care in Germany at the healthcare system level using the Utstein reporting template as the guideline to measure the data collected. Methods This cross-sectional survey collected standardized data from German EDs in 2018. All 759 of the EDs listed in a previously collected ED Directory were contacted in November 2019 using the online-survey tool SoSci Survey. Exclusively descriptive statistical analyses were performed. Absolute as well as relative frequencies, medians, means, ranges, standard deviations (SD) and interquartile ranges (IQR) were reported depending on distribution. Main Results A total of 150 questionnaires of contacted EDs were evaluated (response rate: 19.8%). Hospitals had a median of 403 inpatient beds (n=147). The EDs recorded a median of 30,000 patient contacts (n=136). Eighty-three EDs (55%) had observation units with a median of six beds. The special patient groups were pediatric patients (< 5 years) and older patients (> 75 years) with a median of 1.7% and 25%, respectively. Outpatients accounted for 55%, while 45% were admitted (intensive care unit 5.0%, standard care unit 32.3%, observation unit 6.3%) and 1.2% transferred to another hospital. Conclusions The use of the Utstein reporting template enabled the collection of ED descriptive parameters in Germany. The data can provide a baseline for upcoming reforms on German emergency medicine, and for international comparisons on admission rates, initial triage categories, and patient populations.
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Affiliation(s)
- Florian Wallstab
- Department of Trauma Surgery, Otto von Guericke University Magdeburg, Magdeburg, Germany.
| | - Felix Greiner
- Department of Trauma Surgery, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Wiebke Schirrmeister
- Department of Trauma Surgery, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Markus Wehrle
- Department of Anesthesiology and Intensive Therapy, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Felix Walcher
- Department of Trauma Surgery, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Christian Wrede
- Department of Emergency Medicine, Hospital Berlin-Buch, Berlin, Germany
| | - Kirsten Habbinga
- Department of Interdisciplinary Emergency Medicine, Pius-Hospital, Oldenburg, Germany
| | - Wilhelm Behringer
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria
| | - Dominik Brammen
- Department of Anesthesiology and Intensive Therapy, Otto von Guericke University Magdeburg, Magdeburg, Germany
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14
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Zaboli A, Ausserhofer D, Sibilio S, Paulmichl R, Toccolini E, Pfeifer N, Brigo F, Turcato G. Triage assessment of transitory loss of consciousness in the emergency department-A retrospective observational study. J Adv Nurs 2021; 78:1337-1347. [PMID: 34532861 DOI: 10.1111/jan.15048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 08/22/2021] [Accepted: 09/07/2021] [Indexed: 11/28/2022]
Abstract
AIM To establish how the Manchester Triage System can correctly prioritize patients admitted to the emergency department for transitory loss of consciousness in relation to their risk of presenting severe acute disease. DESIGN A observational retrospective study. METHODS A total of 2291 patients who required a triage evaluation for a transitory loss of consciousness at the emergency department of Merano Hospital between 1 January 2017 and 30 June 2019 were considered. Transitory loss of consciousness was classified according to European Society of Cardiology guidelines. The baseline characteristics of the patients were collected and divided according to the priority level assigned at triage into two different study groups: high priority (red/orange) and low priority (blue/green/yellow). The composite outcome of the study was defined as the diagnosis of a severe acute disease. RESULTS Of the patients enrolled, 17% (390/2291) had a high-priority code and 83% (1901/2291) received a low-priority code. Overall, a severe acute disease was present in 16.9% of patients (387/2291). The Manchester Triage System had a sensitivity of 42.4%, a specificity of 88.1% and an accuracy of 80.4% for predicting severe acute disease. The discriminatory ability had an area under the receiver operating characteristic curve of 0.651 (CI 95%: 0.618-0.685). CONCLUSIONS Despite the good specificity, the low sensitivity does not currently allow the Manchester Triage System to completely exclude patients with a severe acute disease who presented in the emergency department for a transitory loss of consciousness. Therefore, it is important to develop precise nursing tools or assessments that can improve triage performance. IMPACT The assessment of a complex symptom can create difficulties in the stratification of patients in triage, assigning low-priority codes to patients with a severe disease. Additional tools are needed to allow the correct triage assessment of patients presenting with transitory loss of consciousness.
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Affiliation(s)
- Arian Zaboli
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Dietmar Ausserhofer
- College of Health Care Professions Claudiana, Bolzano, Italy.,Department of Public Health, Institute of Nursing Science, University of Basel, Basel, Switzerland
| | - Serena Sibilio
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Rupert Paulmichl
- Department of Cardiology, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Elia Toccolini
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Norbert Pfeifer
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano, Italy
| | - Gianni Turcato
- Emergency Department, Hospital of Merano (SABES-ASDAA), Merano, Italy
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Wireklint SC, Elmqvist C, Göransson KE. An updated national survey of triage and triage related work in Sweden: a cross-sectional descriptive and comparative study. Scand J Trauma Resusc Emerg Med 2021; 29:89. [PMID: 34217351 PMCID: PMC8254961 DOI: 10.1186/s13049-021-00905-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 06/16/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Triage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. According to two national surveys from 2005 to 2011, triage was carried out with different triage scales and without guidelines or formal education. Furthermore, a review from 2010 questioned the scientific evidence for both triage as a method as well as the Swedish five level triage scale Medical Emergency Triage and Treatment System (METTS); nevertheless, METTS was applied in 65% of the EDs in 2011. Subsequently, METTS was renamed to Rapid Emergency Triage and Treatment System (RETTS©). The hypothesis for this study is that the method of triage is still applied nationally and that the use of METTS/RETTS© has increased. Hence, the aim is to describe the occurrence and application of triage and triage related work at Swedish Emergency Departments, in comparison with previous national surveys. METHODS In this cross-sectional study with a descriptive and comparative design, an electronic questionnaire was developed, based on questionnaire from previous studies. The survey was distributed to all hospital affiliated EDs from late March to the middle of July in 2019. The data was analysed with descriptive statistics, by IBM SPSS Statistics, version 26. RESULTS Of the 51 (75%) EDs partaking in the study, all (100%) applied triage, and 92% used the Swedish triage scale RETTS©. Even so, there was low concordance in how RETTS© was applied regarding time frames i.e., how long a patient in respective triage level could wait for assessment by a physician. Additionally, the results show a major diversion in how the EDs performed education in triage. CONCLUSION This study confirms that triage method is nationally implemented across Swedish EDs. RETTS© is the dominating triage scale but cannot be considered as one triage scale due to the variation with regard to time frames per triage level. Further, a diversion in introduction and education in the pivotal role of triage has been shown. This can be counteracted by national guidelines in what triage scale to use and how to perform triage education.
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Affiliation(s)
- Sara C Wireklint
- Emergency Department and Department of Research and Development, Region Kronoberg, Department of Health and Caring Sciences and Centre of Interprofessional Collaboration within Emergency Care (CICE), Linnaeus University, FoU Kronoberg, Sigfridsvägen 5, S-352 57, Växjö, Sweden.
| | - Carina Elmqvist
- Department of Research and Development, Region Kronoberg and Centre of Interprofessional Collaboration within Emergency Care (CICE) at the Department of Health and Caring Sciences, Linnaeus University, Växjö, Sweden
| | - Katarina E Göransson
- Department of Medicine Solna, Karolinska Institutet and Emergency and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
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The new emergency department "Tuscan triage System". Validation study. Int Emerg Nurs 2021; 57:101014. [PMID: 34147875 DOI: 10.1016/j.ienj.2021.101014] [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: 05/13/2020] [Revised: 04/12/2021] [Accepted: 04/30/2021] [Indexed: 11/20/2022]
Abstract
INTRODUCTION A new organizational framework was recently implemented in Tuscan Emergency Departments (EDs), including specific low-priority streaming. A new ED triage system, named "Tuscan Triage System" (TTS), was devised with the purpose of applying this reorganization. METHODS A validation study was designed with the primary aims of assessing the content, face, and criterion validities, and the inter-rater reliability of the TTS. The secondary aim was to estimate the differences in triage level assignation between the previous "Regional Triage System" (RTS) and the TTS. Twenty-four nurses trained for the TTS were enrolled to assign TTS priority levels to 100 triage clinical case vignettes drawn up by the developers of the TTS (reference standard). RESULTS The Content Validity Index - Scale/Average (S-CVI/Ave) of TTS was 0.98. Concerning to face validity, the S-CVI/Ave was 1. The highest adherence of triage level assignation to the reference standard was for levels 1 and 2. The Krippendorff α value was 0.808. Undertriage and overtriage were 10.45% and 14.29%, respectively. Overall, the comparation between RTS and TTS showed a marked shift of level assignation towards TTS low priority levels. CONCLUSIONS The TTS seems to be safe. These results should be confirmed through studies in the real clinical settings.
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Deep ensemble multitask classification of emergency medical call incidents combining multimodal data improves emergency medical dispatch. Artif Intell Med 2021; 117:102088. [PMID: 34127234 DOI: 10.1016/j.artmed.2021.102088] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 11/20/2022]
Abstract
The objective of this work was to develop a predictive model to aid non-clinical dispatchers to classify emergency medical call incidents by their life-threatening level (yes/no), admissible response delay (undelayable, minutes, hours, days) and emergency system jurisdiction (emergency system/primary care) in real time. We used a total of 1 244 624 independent incidents from the Valencian emergency medical dispatch service in Spain, compiled in retrospective from 2009 to 2012, including clinical features, demographics, circumstantial factors and free text dispatcher observations. Based on them, we designed and developed DeepEMC2, a deep ensemble multitask model integrating four subnetworks: three specialized to context, clinical and text data, respectively, and another to ensemble the former. The four subnetworks are composed in turn by multi-layer perceptron modules, bidirectional long short-term memory units and a bidirectional encoding representations from transformers module. DeepEMC2 showed a macro F1-score of 0.759 in life-threatening classification, 0.576 in admissible response delay and 0.757 in emergency system jurisdiction. These results show a substantial performance increase of 12.5 %, 17.5 % and 5.1 %, respectively, with respect to the current in-house triage protocol of the Valencian emergency medical dispatch service. Besides, DeepEMC2 significantly outperformed a set of baseline machine learning models, including naive bayes, logistic regression, random forest and gradient boosting (α = 0.05). Hence, DeepEMC2 is able to: 1) capture information present in emergency medical calls not considered by the existing triage protocol, and 2) model complex data dependencies not feasible by the tested baseline models. Likewise, our results suggest that most of this unconsidered information is present in the free text dispatcher observations. To our knowledge, this study describes the first deep learning model undertaking emergency medical call incidents classification. Its adoption in medical dispatch centers would potentially improve emergency dispatch processes, resulting in a positive impact in patient wellbeing and health services sustainability.
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Das (PR_E-)AUD2IT-Schema als Rückgrat für eine strukturierte Notfallversorgung und Dokumentation nichttraumatologischer kritisch kranker Schockraumpatienten. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00878-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungBei traumatologischen Schockraumpatienten ist die Versorgung seit vielen Jahren standardisiert und auf Basis von Algorithmen vereinheitlicht. Für das breite Spektrum der nichttraumatologischen Notfallpatienten fehlt eine solche einheitliche, übergeordnete Struktur bisher in der Schockraumversorgung. Zwar sind auch hier einzelne Algorithmen und Abläufe üblich und verbreitet, jedoch fehlt ein Gesamtkonzept für die gesamte Notfallversorgung, in das die bestehenden Akronyme eingebunden sind. Durch Vereinheitlichung von Untersuchungsschritten und Dokumentation in der Notfallmedizin könnten Fehler in der Behandlung von Notfallpatienten, verursacht durch Informationsverlust an den Schnittstellen, reduziert werden. Im Rahmen dieser konzeptionellen Arbeit wird daher ein standardisiertes und einfach zu erlernendes Konzept für die Behandlung in der Notfallmedizin vorgestellt. Das (PR_E-)AUD2IT-Schema beinhaltet folgende Phasen: P – Präparation, R – Ressourcen, „_“ – Pause (Team-Time-out) zur strukturierten Übergabe, E – Erstversorgung, A – Anamnese, U – Untersuchung, D2 – Differenzialdiagnosen/apparative Diagnostik, I – Interpretation und T – To-do. Um den Umgang mit zeitkritischen Notfällen nicht zu verzögern, soll dieses Konzept auch von unerfahrenen Mitarbeitern schnell und sicher angewendet werden können. Das (PR_E-)AUD2IT-Schema ist ein didaktisches Instrument zur Strukturierung und Gliederung einer Schockraumversorgung nichttraumatologisch kritisch kranker Patienten und ihrer Dokumentation.
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Erkelens DC, Zwart DL, van der Meer GH, Wouters LT, De Groot E, Damoiseaux RA, Hoes AW, Rutten FH. Is the time of calling helpful for differentiating transient ischaemic attack and stroke from mimics in primary care out-of-hours services? A cross-sectional study. BMJ Open 2020; 10:e041408. [PMID: 33334837 PMCID: PMC7747588 DOI: 10.1136/bmjopen-2020-041408] [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: 11/12/2022] Open
Abstract
OBJECTIVES Telephone triage of patients suspected of transient ischaemic attack (TIA) or stroke is challenging. Both TIA and stroke more likely occur during daytime, with a peak in the morning hours. Thus, the time of calling might be a helpful determinant during telephone triage. We assessed the time of calling in patients with stroke-like symptoms who called the out-of-hours services in primary care (OHS-PC), and evaluated whether the time of calling differed between patients with TIA or stroke compared with those with mimics. DESIGN Cross-sectional study. SETTING Six OHS-PC locations in the Netherlands. PARTICIPANTS 1269 telephone triage recordings of patients calling the OHS-PC because of stroke-like symptoms. We collected information on patient characteristics, symptoms, time of calling and urgency allocation. The final diagnosis related to each triage call was based on letters from the neurologist (retrieved from the patient's general practitioner). PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measures were the time of calling hourly and 4 hourly, and the risk of TIA or stroke/hour. The secondary outcome measure was the risk ratio of TIA or stroke in the morning (08:00-12:00h) versus other hours. RESULTS Mean age was 68.6 (SD±18.5) years, 56.9% were women and 50.0% had a TIA or stroke. The risk ratio of TIA or stroke among people calling with stroke-like symptoms between 08:00-12:00h versus other hours was 1.13 (95% CI 1.00 to 1.28, p=0.070). After correction for age and sex, the adjusted risk ratio was 0.94 (95% CI 0.80 to 1.10, p=0.434). CONCLUSION In patients who called the OHS-PC because of stroke-like symptoms, the time of calling did not differ between patients with TIA or stroke and patients with mimics. TRIAL REGISTRATION NUMBER The Netherlands National Trial Registry (NTR7331).
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Affiliation(s)
- Daphne Ca Erkelens
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dorien L Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gerben H van der Meer
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Loes Tcm Wouters
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Esther De Groot
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger Amj Damoiseaux
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Ausserhofer D, Zaboli A, Pfeifer N, Siller M, Turcato G. Performance of the Manchester Triage System in patients with dyspnoea: A retrospective observational study. Int Emerg Nurs 2020; 53:100931. [DOI: 10.1016/j.ienj.2020.100931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 10/23/2022]
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21
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Moura BRS, Nogueira LDS. Performance of the rapid triage conducted by nurses at the emergency entrance. Rev Lat Am Enfermagem 2020; 28:e3378. [PMID: 33084778 PMCID: PMC7575239 DOI: 10.1590/1518-8345.3467.3378] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/28/2020] [Indexed: 11/29/2022] Open
Abstract
Objective: to compare the performance of the rapid triage conducted by nurses at the
emergency entrance and of the Manchester Triage System (MTS) in identifying
the priority level of care for patients with spontaneous demand and
predicting variables related to hospitalization. Method: a cross-sectional study carried out in an Emergency Department (ED) of a
university hospital in São Paulo. The priority levels established in the
rapid triage performed by nurses were high priority (patients of spontaneous
demand directed to the emergency room) or low priority (those referred to
the institution’s usual flow). Diagnostic accuracy measures were calculated
to assess the performance of the indexes. Results: of the 173 patients (52.0% female, with mean age of 60.4 ± 21.2 years old)
evaluated, it was observed that rapid triage was more inclusive for high
priority and had better sensitivity and worse specificity than the MTS. The
probability of non-severe patients being admitted to the emergency
observation unit was lower due to the rapid triage. For the prediction of
the other variables, the systems presented unsatisfactory results. Conclusion: the nurses overestimated the classification of patients as high priority, and
rapid triage performed better than MTS in predicting admission to the
emergency observation unit.
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Al-Otmy SS, Abduljabbar AZ, Al-Raddadi RM, Farahat F. Factors associated with non-urgent visits to the emergency department in a tertiary care centre, western Saudi Arabia: cross-sectional study. BMJ Open 2020; 10:e035951. [PMID: 33028545 PMCID: PMC7539577 DOI: 10.1136/bmjopen-2019-035951] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 04/24/2020] [Accepted: 07/14/2020] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES To explore magnitude and factors associated with non-urgent visits to the emergency department (ED) in a tertiary care centre, western Saudi Arabia. DESIGN A cross-sectional study. SETTING ED of a tertiary care hospital in western Saudi Arabia. PARTICIPANTS 400 patients, both men and women. INTERVENTIONS An interview-based questionnaire was administered to a consecutive sample of patients who visited the ED during morning shifts, where primary healthcare centres (PHCs) and outpatient clinics were available. PRIMARY OUTCOME MEASURE ED visits classified as non-urgent versus urgent (excluding life-threatening conditions) based on the Canadian Triage and Acuity Scale (CTAS). Levels IV and V were classified as non-urgent. RESULTS Majority of the cases were adult (97.3%) and half of them were women (54.8%). Non-urgent visits represented 78.5% among non-life-threatening cases. One-third of the patients (33.8%) had three visits or more to the ED during the past year. Main reasons for visiting the ED were perception that the condition was urgent (42.0%), easy access (25.5%) and limited resources and services at the PHCs (17.8%). Patients 40-50 years old were more likely to have non-urgent visits (OR=3.21, 95% CI 1.15 to 8.98). However, likelihood of non-urgent visits was significantly lower among patients with cancer (OR=0.37, 95% CI 0.19 to 0.72) and cardiovascular disease (OR=0.43, 95% CI 0.23 to 0.83), and those who live near the hospital (OR=0.49, 95% CI 0.28 to 0.88). CONCLUSIONS The current study reported overuse of the ED. Enhancement of the primary care services, in concordance with community awareness, is an important component to reduce burden due to non-urgent use of the ED.
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Affiliation(s)
- Saja S Al-Otmy
- Family medicine resident, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | | | - Rajaa M Al-Raddadi
- Community Medicine Department, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Fayssal Farahat
- Infection Prevention and Control Department, King Abdulaziz Medical City, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center (KAIMRC), Jeddah, Saudi Arabia
- College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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Magnusson C, Herlitz J, Axelsson C. Pre-hospital triage performance and emergency medical services nurse's field assessment in an unselected patient population attended to by the emergency medical services: a prospective observational study. Scand J Trauma Resusc Emerg Med 2020; 28:81. [PMID: 32807224 PMCID: PMC7430123 DOI: 10.1186/s13049-020-00766-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 07/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In Sweden, the rapid emergency triage and treatment system (RETTS-A) is used in the pre-hospital setting. With RETTS-A, patients triaged to the lowest level could safely be referred to a lower level of care. The national early warning score (NEWS) has also shown promising results internationally. However, a knowledge gap in optimal triage in the pre-hospital setting persists. This study aimed to evaluate RETTS-A performance, compare RETTS-A with NEWS and NEWS 2, and evaluate the emergency medical service (EMS) nurse's field assessment with the physician's final hospital diagnosis. METHODS A prospective, observational study including patients (≥16 years old) transported to hospital by the Gothenburg EMS in 2016. Three comparisons were made: 1) Combined RETTS-A levels orange and red (high acuity) compared to a predefined reference emergency, 2) RETTS-A high acuity compared to NEWS and NEWS 2 score ≥ 5, and 3) Classification of pre-hospital nurse's field assessment compared to hospital physician's diagnosis. Outcomes of the time-sensitive conditions, mortality and hospitalisation were examined. The statistical tests included Mann-Whitney U test and Fisher's exact test, and several binary classification tests were determined. RESULTS Overall, 4465 patients were included (median age 69 years; 52% women). High acuity RETTS-A triage showed a sensitivity of 81% in prediction of the reference patient with a specificity of 64%. Sensitivity in detecting a time-sensitive condition was highest with RETTS-A (73%), compared with NEWS (37%) and NEWS 2 (35%), and specificity was highest with NEWS 2 (83%) when compared with RETTS-A (54%). The negative predictive value was higher in RETTS-A (94%) compared to NEWS (91%) and NEWS 2 (92%). Eleven per cent of the final diagnoses were classified as time-sensitive while the nurse's field assessment was appropriate in 84% of these cases. CONCLUSIONS In the pre-hospital triage of EMS patients, RETTS-A showed sensitivity that was twice as high as that of both NEWS and NEWS 2 in detecting time-sensitive conditions, at the expense of lower specificity. However, the proportion of correctly classified low risk triaged patients (green/yellow) was higher in RETTS-A. The nurse's field assessment of time-sensitive conditions was appropriate in the majority of cases.
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Affiliation(s)
- Carl Magnusson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Johan Herlitz
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Pre Hospen-Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Christer Axelsson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Pre Hospen-Centre for Prehospital Research, Faculty of Caring Science, Work Life and Social Welfare, University of Borås, Borås, Sweden
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Lim BJV, Wahab SFA, Kueh YC. Validity and Reliability of Emergency Severity Index and Conventional Three-Tier Triage System in the Emergency Department, Hospital Universiti Sains Malaysia. Malays J Med Sci 2020; 27:90-100. [PMID: 32788845 PMCID: PMC7409571 DOI: 10.21315/mjms2020.27.2.10] [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: 09/04/2019] [Accepted: 03/07/2020] [Indexed: 11/07/2022] Open
Abstract
Background The study aimed to examine the reliability and validity of the existing three-tier triaging system and a new five-level emergency triaging system, emergency severity index (ESI), in the Emergency Department (ED) of Hospital Universiti Sains Malaysia (HUSM). Methods This study was conducted in HUSM’s ED over two study periods. In the first three months, 300 patients were triaged under the three-tier triaging system, and, in the subsequent three months, 280 patients were triaged under the ESI. The patients were triaged by junior paramedics and the triage records were retained and later re-triaged by senior paramedics. The inter-rater reliability was evaluated using Cohen's Kappa statistics. The acuity ratings of the junior paramedics were compared with those of the expert panel to determine the sensitivity and specificity of each acuity level for both the ESI and the three-tier triaging system. The over-triage rate, under-triage rate, amount of resources used, admission rate and discharge rate were also determined. Results The inter-rater agreement for the three-tier triaging system was 0.81 while that of the ESI was 0.75. The ESI had a higher average sensitivity of 74.3% and a specificity of 94.4% while the three-tier system’s average sensitivity was 68.5% and its specificity 87.0%. The average under-triage and over-triage rates for the ESI were 10.7% and 6.2%, respectively, which were lower than the three-tier system’s average under-triage rate of 13.1% and over-triage rate of 17.1%. The urgency levels of both the ESI and the three-tier system were associated with increased admission rates and resources used in the ED. Conclusion The ESI’s inter-rater reliability was comparable to the three-tier triaging system and it demonstrated better validity than the existing three-tier system.
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Affiliation(s)
- Ban Jin Victor Lim
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Shaik Farid Ab Wahab
- Department of Emergency Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
| | - Yee Cheng Kueh
- Unit of Biostatistics and Research Methodology, School of Medical Sciences, Universiti Sains Malaysia, Kelantan, Malaysia
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Physicians' Disease Severity Ratings are Non-Inferior to the Emergency Severity Index. J Clin Med 2020; 9:jcm9030762. [PMID: 32168931 PMCID: PMC7141189 DOI: 10.3390/jcm9030762] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 02/29/2020] [Accepted: 03/07/2020] [Indexed: 11/30/2022] Open
Abstract
Our objective was to compare informal physicians’ disease severity ratings (PDSR) at presentation with the well-established Emergency Severity Index (ESI) in order to test for non-inferiority of the discriminatory ability regarding hospitalization, intensive care, and mortality. We made a prospective observational study with consecutive enrollment. At presentation, the PDSR and subsequently Emergency Severity Index (ESI) levels were recorded. The primary outcome was the non-inferiority of the discriminatory ability (PDSR versus ESI) regarding hospitalization, intensive care, and mortality. The secondary outcomes were the reliability, the predictive validity, and the safety of PDSR. We included 6859 patients. The median age was 51 years (interquartile range (IQR) = 33 to 72 years); 51.4% were males. There were 159 non-survivors (2.4%) at the 30 day follow-up. The PDSR’s discriminatory ability was non-inferior to the ESI’s discriminatory ability. The safety assessment showed mortality of <0.5% in low-acuity patients in both tools. The predictive validity increased by 3.5 to 7 times if adding high-acuity PDSR to ESI in all categories with mortality of >1%. Our data showed the non-inferiority of PDSR compared with ESI regarding discriminatory ability, a moderate reliability, and an acceptable safety of both tools.
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Huntley AL, Davies B, Jones N, Rooney J, Goyder P, Purdy S, Baxter H. Determining when a hospital admission of an older person can be avoided in a subacute setting: a systematic review and concept analysis. J Health Serv Res Policy 2019; 25:252-264. [PMID: 31805793 DOI: 10.1177/1355819619886885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To conduct a systematic review of the evidence for when a hospital admission for an older person can be avoided in subacute settings. We examined the definition of admission avoidance and the evidence for the factors that are required to avoid admission to hospital in this setting. METHODS Using defined PICOD criteria, we conducted searches in three databases (Medline, Embase and Cinahl) from January 2006 to February 2018. References were screened by title and abstract followed by full paper screening by two reviewers. Additional studies were searched from the grey literature, experts in the field and forward and backward referencing. Data were narratively described, and concept analysis was used to investigate the definition of admission avoidance. RESULTS A total of 17 studies were considered eligible for review; eight provided a definition of admission avoidance and 10 described admission avoidance criteria. We identified three factors which play a key role in admission avoidance in the subacute setting: (1) ambulatory care sensitive conditions and common medical scenarios for the older person, which included respiratory infections or pneumonia, urinary tract infections and catheter care, dehydration and associated symptoms, falls and behavioural management, and managing ongoing chronic conditions; (2) criteria/tools, referring to interventions that have used clinical expertise in conjunction with a range of general and geriatric triage tools; in condition-specific interventions, the decision whether to admit or not was based on level of risk determined by defined clinical tools; and (3) personnel and resources, referring to the need for experts to make the initial decision to avoid an admission. Supervision by nurses or physicians was still needed at subacute level, requiring resources such as short-stay beds, intravenous antibiotic treatment or fluids for rehydration and rapid access to laboratory tests. CONCLUSION The review identified a set of criteria for ambulatory care sensitive conditions and common medical scenarios for the older person that can be treated in the subacute setting with appropriate tools and resources. This information can help commissioners and care providers to take on these important elements and deliver them in a locally designed way.
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Affiliation(s)
- Alyson L Huntley
- Senior Research Fellow, Centre of Academic Primary Care, School of Population Science, University of Bristol, UK
| | - Ben Davies
- Honorary Senior Research Associate, Centre of Academic Primary Care, School of Population Science, University of Bristol, UK
| | - Nigel Jones
- Consultant Physician, North Bristol Trust, UK
| | - James Rooney
- Senior Project Manager, Transformation & Consultancy, NHS Bristol, North Somerset & South Gloucestershire CCG, UK
| | - Peter Goyder
- General Practitioner Commissioner, NHS Bristol, North Somerset & South Gloucestershire CCG, UK
| | - Sarah Purdy
- Pro Vice-Chancellor, Centre of Academic Primary Care, School of Population Science, University of Bristol, UK
| | - Helen Baxter
- Senior Research Associate, Centre of Academic Primary Care, School of Population Science, University of Bristol, UK
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Validity and Reliability of the Emergency Severity Index in a Spanish Hospital. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16224567. [PMID: 31752212 PMCID: PMC6888397 DOI: 10.3390/ijerph16224567] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/21/2019] [Revised: 11/08/2019] [Accepted: 11/14/2019] [Indexed: 11/17/2022]
Abstract
Saturation in hospital emergency departments is one of the main safety problems for the patient, which can generate negative consequences for their health. In response to this issue, triage systems are developed to organize the flow of patients in order to allow the most urgent ones to be treated first. The Emergency Severity Index (ESI) is the most used triage system in the USA and it has been implemented in the General Hospital of La Palma since 2010. The objective of this study is the validation of the ESI adapted to our hospital through the study of its degree of reliability, as well as the criterion validity. The sample consisted of 240 randomly selected cases, with proportional representation of emergencies attended in 2015 and their fraction of urgent ones (Levels 1 and 2). Criterion validity was estimated by sensitivity, specificity, and predictive result values. For reliability, the degree of agreement among the nurses was studied by means of the adapted kappa index kc2. Criterion validity showed a sensitivity of 89% (85-93%) and a specificity of 97% (94-99%), with a positive predictive value of 68% (62-74%) and a negative predictive value of 99% (98-100%) for the discrimination of urgent cases. The reliability analysis showed a kc2 = 0.94 (0.84-0.99) index, a very good agreement according to Landis-Koch criteria. The results of our study have shown adequate validity and reliability in the adaptation and implementation of an ESI triage system suited to the specific conditions of a hospital emergency service in Spain.
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Comparison of Reliability and Validity of the Chinese Four-Level and Three-District Triage Standard and the Australasian Triage Scale. Emerg Med Int 2019; 2019:8490152. [PMID: 31827931 PMCID: PMC6885288 DOI: 10.1155/2019/8490152] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/22/2019] [Accepted: 10/21/2019] [Indexed: 11/17/2022] Open
Abstract
Emergency triage is an important tool for prioritizing urgent or critical patients, and its effect needs to be investigated and evaluated. This observational study aimed to compare the reliability and validity of the Chinese four-level and three-district triage standard (CHT) and the Australasian Triage Scale (ATS) in an adult emergency department of a general hospital in China. From 2016-01 to 2017-01, twelve nurses independently performed on-site triage of 254 patients and 1552 patients to assess the scales' reliability and validity, respectively. The interrater reliability, as assessed by the weighted k scores, was 0.686 (95% CI 0.608–0.757) for the CHT and 0.731 (95% CI 0.663–0.790) for the ATS, and the k scores between the CHT and the ATS were 0.630 (95% CI 0.594–0.669). Temperature, respiration, pulse, blood oxygen saturation, waiting time, treatment time, emergency disposition, hospitalization rate, and mortality were significantly associated with the triage levels of the CHT and ATS (p < 0.001). The area under the receiver operating characteristic (AUROC) curve values of the CHT and ATS for predicting intensive care treatment were 0.845 (95% CI: 0.825–0.866) and 0.740 (95% CI: 0.715–0.765), respectively. The reliability and validity of the CHT and ATS were moderate, and both of them can be used to identify critical patients in emergency departments. It is necessary to further improve the triage system in terms of structure and content.
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Pouyamehr A, Mirhaghi A, Sharifi MD, Eshraghi A. Comparison between Emergency Severity Index and Heart Failure Triage Scale in heart failure patients: A randomized clinical trial. World J Emerg Med 2019; 10:215-221. [PMID: 31534595 DOI: 10.5847/wjem.j.1920-8642.2019.04.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND It is not clear whether Emergency Severity Index (ESI) is valid to triage heart failure (HF) patients and if HF patients benefit more from a customized triage scale or not. The aim of study is to compare the effect of Heart Failure Triage Scale (HFTS) and ESI on mistriage among patients with HF who present to the emergency department (ED). METHODS A randomized clinical trial was conducted from April to June 2017. HF patients with dyspnea were randomly assigned to HFTS or ESI groups. Triage level, used resources and time to electrocardiogram (ECG) were compared between both groups among HF patients who were admitted to coronary care unit (CCU), cardiac unit (CU) and discharged patients from the ED. Content validity was examined using Kappa designating agreement on relevance (K*). Reliability of both scale was evaluated using inter-observer agreement (Kappa). RESULTS Seventy-three and 74 HF patients were assigned to HFTS and ESI groups respectively. Time to ECG in HFTS group was significantly shorter than that of ESI group (2.05 vs. 16.82 minutes). Triage level between HFTS and ESI groups was significantly different among patients admitted to CCU (1.0 vs. 2.8), cardiac unit (2.26 vs. 3.06) and discharged patients from the ED (3.53 vs. 2.86). Used resources in HFTS group was significantly different among triage levels (H=25.89; df=3; P<0.001). CONCLUSION HFTS is associated with less mistriage than ESI for triaging HF patients. It is recommended to make use of HFTS to triage HF patients in the ED.
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Affiliation(s)
- Ahmad Pouyamehr
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Mirhaghi
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Davood Sharifi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Eshraghi
- Department of Cardiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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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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The introduction of the Early Warning Score in the Emergency Department: A retrospective cohort study. Int Emerg Nurs 2019; 45:31-35. [DOI: 10.1016/j.ienj.2019.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 02/25/2019] [Accepted: 03/24/2019] [Indexed: 11/21/2022]
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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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Zachariasse JM, van der Hagen V, Seiger N, Mackway-Jones K, van Veen M, Moll HA. Performance of triage systems in emergency care: a systematic review and meta-analysis. BMJ Open 2019; 9:e026471. [PMID: 31142524 PMCID: PMC6549628 DOI: 10.1136/bmjopen-2018-026471] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/23/2019] [Accepted: 03/28/2019] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To assess and compare the performance of triage systems for identifying high and low-urgency patients in the emergency department (ED). DESIGN Systematic review and meta-analysis. DATA SOURCES EMBASE, Medline OvidSP, Cochrane central, Web of science and CINAHL databases from 1980 to 2016 with the final update in December 2018. ELIGIBILITY CRITERIA Studies that evaluated an emergency medical triage system, assessed validity using any reference standard as proxy for true patient urgency and were written in English. Studies conducted in low(er) income countries, based on case scenarios or involving less than 100 patients were excluded. REVIEW METHODS Reviewers identified studies, extracted data and assessed the quality of the evidence independently and in duplicate. The Quality Assessment of studies of Diagnostic Accuracy included in Systematic Reviews -2 checklist was used to assess risk of bias. Raw data were extracted to create 2×2 tables and calculate sensitivity and specificity. ED patient volume and casemix severity of illness were investigated as determinants of triage systems' performance. RESULTS Sixty-six eligible studies evaluated 33 different triage systems. Comparisons were restricted to the three triage systems that had at least multiple evaluations using the same reference standard (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System). Overall, validity of each triage system to identify high and low-urgency patients was moderate to good, but performance was highly variable. In a subgroup analysis, no clear association was found between ED patient volume or casemix severity of illness and triage systems' performance. CONCLUSIONS Established triage systems show a reasonable validity for the triage of patients at the ED, but performance varies considerably. Important research questions that remain are what determinants influence triage systems' performance and how the performance of existing triage systems can be improved.
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Affiliation(s)
- Joany M Zachariasse
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Vera van der Hagen
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nienke Seiger
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | | | - Mirjam van Veen
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
- Pediatrics, Groene Hart Ziekenhuis, Gouda, The Netherlands
| | - Henriette A Moll
- Department of Pediatrics, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
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Ibanez-Sanchez G, Fernandez-Llatas C, Martinez-Millana A, Celda A, Mandingorra J, Aparici-Tortajada L, Valero-Ramon Z, Munoz-Gama J, Sepúlveda M, Rojas E, Gálvez V, Capurro D, Traver V. Toward Value-Based Healthcare through Interactive Process Mining in Emergency Rooms: The Stroke Case. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16101783. [PMID: 31137557 PMCID: PMC6572362 DOI: 10.3390/ijerph16101783] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/10/2019] [Accepted: 05/14/2019] [Indexed: 12/19/2022]
Abstract
The application of Value-based Healthcare requires not only the identification of key processes in the clinical domain but also an adequate analysis of the value chain delivered to the patient. Data Science and Big Data approaches are technologies that enable the creation of accurate systems that model reality. However, classical Data Mining techniques are presented by professionals as black boxes. This evokes a lack of trust in those techniques in the medical domain. Process Mining technologies are human-understandable Data Science tools that can fill this gap to support the application of Value-Based Healthcare in real domains. The aim of this paper is to perform an analysis of the ways in which Process Mining techniques can support health professionals in the application of Value-Based Technologies. For this purpose, we explored these techniques by analyzing emergency processes and applying the critical timing of Stroke treatment and a Question-Driven methodology. To demonstrate the possibilities of Process Mining in the characterization of the emergency process, we used a real log with 9046 emergency episodes from 2145 stroke patients that occurred from January 2010 to June 2017. Our results demonstrate how Process Mining technology can highlight the differences between the flow of stroke patients compared with that of other patients in an emergency. Further, we show that support for health professionals can be provided by improving their understanding of these techniques and enhancing the quality of care.
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Affiliation(s)
| | - Carlos Fernandez-Llatas
- SABIEN-ITACA, Universitat Politècnica de València, 46022 València, Spain.
- Unidad Mixta de Reingeniería de Procesos Sociosanitarios (eRPSS), Instituto de Investigaciń Sanitaria del Hospital Universitario y Politecnico La Fe, Bulevar Sur S/N, 46026 València, Spain.
| | | | - Angeles Celda
- Hospital General de Valencia, Av. de les Tres Creus, 2, 46014 València, Spain.
| | - Jesus Mandingorra
- Hospital General de Valencia, Av. de les Tres Creus, 2, 46014 València, Spain.
- School of Nursing, Universidad Católica de Valencia, 46022 València, Spain.
| | | | - Zoe Valero-Ramon
- SABIEN-ITACA, Universitat Politècnica de València, 46022 València, Spain.
| | - Jorge Munoz-Gama
- School of Engineering, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile.
| | - Marcos Sepúlveda
- School of Engineering, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile.
| | - Eric Rojas
- School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile.
| | - Víctor Gálvez
- School of Engineering, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile.
| | - Daniel Capurro
- School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8320000, Chile.
| | - Vicente Traver
- SABIEN-ITACA, Universitat Politècnica de València, 46022 València, Spain.
- Unidad Mixta de Reingeniería de Procesos Sociosanitarios (eRPSS), Instituto de Investigaciń Sanitaria del Hospital Universitario y Politecnico La Fe, Bulevar Sur S/N, 46026 València, Spain.
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Roudi MH, Malekzadeh J, Ebrahimi M, Mirhaghi A, Shakeri M. Comparison between Emergency Severity Index plus peak flow meter and Emergency Severity Index in the dyspneic patients with chronic obstructive pulmonary disease: A randomized clinical trial. Turk J Emerg Med 2019; 19:68-72. [PMID: 31065606 PMCID: PMC6495057 DOI: 10.1016/j.tjem.2019.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 01/25/2019] [Accepted: 01/29/2019] [Indexed: 11/28/2022] Open
Abstract
Introduction It is unclear whether the Emergency Severity Index (ESI) can identify high-risk patients with Chronic Obstructive Pulmonary Disease (COPD). This study aims to compare the mistriage rates of the ESI plus the Peak Expiratory Flowmeter (PEF) approach and ESI approach among dyspneic patients with COPD. Methods This study was a randomized clinical trial conducted between July and October 2018. We randomly assigned COPD patients with dyspnea to the ESI + PEF or ESI groups. Triage levels, disposition rates, number of resources used, and time to first physician contact were compared in patients admitted to the Intensive Care Unit (ICU), the Pulmonary Care Unit (PU), or discharged from the ED. Reliability of the ESI was evaluated by using the interobserver agreement (Kappa). Results Seventy COPD patients were equally assigned to the ESI + PEF and ESI groups. The under-triage rates were 11.42% and 0%, the over-triage rates were 31.42% and 2.85% in the ESI and ESI + PEF groups, respectively. The triage levels of the patients admitted to the ICU (2 vs. 3), the PU (2 vs. 4), or discharged from the ED (3 vs. 2) were significantly different between the ESI + PEF and ESI groups. Conclusions Addition of PEF to the ESI provides a more accurate method for triaging COPD patients compared to ESI alone. We recommend using PEF for the triage of COPD patients in the ED.
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Affiliation(s)
- Mahin Hamechizfahm Roudi
- Department of Medical-Surgical Nursing, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Javad Malekzadeh
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohsen Ebrahimi
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amir Mirhaghi
- Nursing and Midwifery Care Research Center, Mashhad University of Medical Sciences, Mashhad, Iran
| | - MohammadTaghi Shakeri
- Department of Biostatistics and Epidemiology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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Sacoman TM, Beltrammi DGM, Andrezza R, Cecílio LCDO, Reis AACD. Implantação do Sistema de Classificação de Risco Manchester em uma rede municipal de urgência. SAÚDE EM DEBATE 2019. [DOI: 10.1590/0103-1104201912105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Os serviços de urgência e emergência hospitalares e não hospitalares são habitualmente utilizados como portas de entrada dos sistemas de saúde. A hipótese do excesso de demanda por esses serviços é insuficiente para explicar os desfechos clínicos desfavoráveis que resultam do fenômeno da superlotação, relacionado a aspectos organizativos desses próprios serviços. Diante desse cenário, a reorganização das entradas dos serviços de urgência e emergência tornou-se primordial. O artigo apresenta e analisa a implantação do Sistema de Classificação de Risco de Manchester em uma rede municipal de urgência e emergência da região metropolitana de São Paulo, a maior do hemisfério Sul, e permite compreender como o aprimoramento do uso da classificação de risco, prevista em diversas políticas do Sistema Único de Saúde, pode se constituir em potente tecnologia aplicada à gestão do cuidado e dos serviços de urgência e emergência.
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Lee SB, Kim DH, Kim T, Kang C, Lee SH, Jeong JH, Kim SC, Park YJ, Lim D. Emergency Department Triage Early Warning Score (TREWS) predicts in-hospital mortality in the emergency department. Am J Emerg Med 2019; 38:203-210. [PMID: 30795946 DOI: 10.1016/j.ajem.2019.02.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/30/2019] [Accepted: 02/05/2019] [Indexed: 01/05/2023] Open
Abstract
AIM The purpose is to assess the adequacy of the National Early Warning Score (NEWS) in the emergency department (ED) and the usefulness of the Triage in Emergency Department Early Warning Score (TREWS) that has been developed using the NEWS in the ED. METHODS In this retrospective observational cohort study, we performed univariable and multivariable regression analyses with 81,520 consecutive ED patients to develop a new scoring system, the TREWS. The primary outcome was in-hospital mortality within 24 h, and secondary outcomes were in-hospital mortality within 48 h, 7 days, and 30 days. The prognostic properties of the TREWS were compared with those of the NEWS, Modified Early Warning Score (MEWS), and Rapid Emergency Medicine Score (REMS) using the area under the receiver operating characteristic curve (AUC) technique. RESULTS The AUC of the TREWS for in-hospital mortality within 24 h was 0.906 (95% CI, 0.903-0.908), those of the NEWS, MEWS, and REMS were 0.878 (95% CI, 0.875-0.881), 0.857 (95% CI, 0.854-0.860), and 0.834 (95% CI, 0.831-0.837), respectively. Differences in the AUC between the TREWS and NEWS, the TREWS and MEWS, and the TREWS and REMS were 0.028 (95% CI, 0.022-0.033; p < .001), 0.049 (95% CI, 0.041-0.057; p < .001), and 0.072 (95% CI, 0.063-0.080; p < .001), respectively. The TREWS showed significantly superior performance in predicting secondary outcomes. CONCLUSION The TREWS predicts in-hospital mortality within 24 h, 48 h, 7 days, and 30 days better than the NEWS, MEWS, and REMS for patients arriving at the ED.
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Affiliation(s)
- Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea.
| | - Taeyun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Yong Joo Park
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Daesung Lim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Hasselbalch RB, Pries-Heje M, Schultz M, Plesner LL, Ravn L, Lind M, Greibe R, Jensen BN, Høi-Hansen T, Carlson N, Torp-Pedersen C, Rasmussen LS, Iversen K. The Copenhagen Triage Algorithm is non-inferior to a traditional triage algorithm: A cluster-randomized study. PLoS One 2019; 14:e0211769. [PMID: 30716123 PMCID: PMC6361446 DOI: 10.1371/journal.pone.0211769] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 01/19/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction Triage systems with limited room for clinical judgment are used by emergency departments (EDs) worldwide. The Copenhagen Triage Algorithm (CTA) is a simplified triage system with a clinical assessment. Methods The trial was a non-inferiority, two-center cluster-randomized crossover study where CTA was compared to a local adaptation of Adaptive Process Triage (ADAPT). CTA involves initial categorization based on vital signs with a final modification based on clinical assessment by an ED nurse. We used 30-day mortality with a non-inferiority margin at 0.5%. Predictive performance was compared using Receiver Operator Characteristics. Results We included 45,347 patient visits, 23,158 (51%) and 22,189 (49%) were triaged with CTA and ADAPT respectively with a 30-day mortality of 3.42% and 3.43% (P = 0.996) a difference of 0.01% (95% CI: -0.34 to 0.33), which met the non-inferiority criteria. Mortality at 48 hours was 0.62% vs. 0.71%, (P = 0.26) and 6.38% vs. 6.61%, (P = 0.32) at 90 days for CTA and ADAPT. CTA triaged at significantly lower urgency level (P<0.001) and was superior in predicting 30-day mortality, Area under the curve: 0.67 (95% CI 0.65–0.69) compared to 0.64 for ADAPT (95% CI 0.62–0.66) (P = 0.03). There were no significant differences in rate of admission to the intensive care unit, length of stay, waiting time nor rate of readmission within 30 or 90 days. Conclusion A novel triage system based on vital signs and a clinical assessment by an ED nurse was non-inferior to a traditional triage algorithm by short term mortality, and superior in predicting 30-day mortality. Trial registration Clinicaltrials.gov NCT02698319
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Affiliation(s)
| | - Mia Pries-Heje
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Martin Schultz
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | | | - Lisbet Ravn
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Morten Lind
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Rasmus Greibe
- Department of Cardiology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Thomas Høi-Hansen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
| | - Nicholas Carlson
- Department of Cardiology, Gentofte Hospital, Copenhagen, Denmark
- The Danish Heart Foundation, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Department of Health, Science and Technology, Aalborg University and Department of Cardiology and Epidemiology/Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia, Center of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Iversen
- Department of Cardiology, Herlev-Gentofte Hospital, Copenhagen, Denmark
- Department of Emergency Medicine, Herlev-Gentofte Hospital, Copenhagen, Denmark
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Andrade-Silva FB, Takemura RL, Bellato RT, Leonhardt MDC, Kojima KE, Silva JDS. VALIDITY AND RELIABILITY OF THE MANCHESTER SCALE USED IN THE ORTHOPEDIC EMERGENCY DEPARTMENT. ACTA ORTOPEDICA BRASILEIRA 2019; 27:50-54. [PMID: 30774531 PMCID: PMC6362691 DOI: 10.1590/1413-785220192701191577] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objectives: To describe the clinical utility of the Manchester triage scale adapted for orthopedic emergency departments and to evaluate its validity in identifying patients with the need for hospital care and its reliability when reproduced by different professionals. Methods: Five triage flowcharts were developed based on the Manchester scale for the following orthopedic disorders: traumatic injuries, joint pain, vertebral pain, postoperative disorders, and musculoskeletal infections. A series of patients triaged by two orthopedists was analyzed to assess the concordance between the evaluators (reliability) and the validity of the Manchester scale as predictive of severity. Results: The reliability analysis included 231 patients, with an inter-observer agreement of 84% (Kappa = 0.77, p <0.001). The validity analysis included 138 patients. The risk category had a strong association with the need for hospital care in patients with trauma (OR = 6.57, p = 0.001) and was not significant for non-traumatic disorders (OR = 2.42; p = 0.208). The overall sensitivity and specificity were 64% and 76%, respectively. Conclusion: The evaluated system presented high reliability. Its validity was adequate, with good sensitivity for identifying patients requiring hospital care among those with traumatic lesions. However, the sensitivity was low for patients with non-traumatic lesions. Level of Evidence III, Retrospective Study.
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Sung S, Kang CY, Lee HY, Lee JH, Kim OH, Youk H, Lee KH. Correlation between the pre-hospital triage scale and emergency department triage scale. HONG KONG J EMERG ME 2019. [DOI: 10.1177/1024907918793780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background:While emergency patient triage system is effective when the pre-hospital triage acuity scale is linked with the in-hospital triage acuity scale. However, the 119 emergency medical triage system and the Korea Triage and Acuity Scale are not linked in Korea.Objective:This study aimed to investigate the correlation between the two triage systems and to utilize the results as basic data for the future development of a pre-hospital triage system.Methods:Among the 1114 patients who visited a regional emergency medical center by a 119 ambulance from April to May 2016, we analyzed the correlation between the pre-hospital and in-hospital triage systems based on the general characteristics of the patients and their reason of hospital visit (non-trauma or trauma).Results:Upon reclassifying the pre-hospital and in-hospital triage systems into three levels, among the 289 patients (28.1%) in level 3 of the pre-hospital triage, 79 (27.3%) were reclassified as the highest level (Resuscitation) in the in-hospital triage. The kappa coefficient as a measure of agreement between the two triage systems was very low at 0.211 (95% confidence interval, 0.164–0.258), and the kappa coefficient of the paramedic category was 0.232 (95% confidence interval, 0.161–0.303).Conclusion:There is a low agreement between the pre-hospital and in-hospital triage systems.
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Affiliation(s)
- Sil Sung
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Chan Young Kang
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hee Young Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jung Hun Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Oh Hyun Kim
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Youk
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Kang Hyun Lee
- Department of Emergency Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Breidthardt T, Brunner-Schaub N, Balmelli C, Insenser JJS, Burri-Winkler K, Geigy N, Mundorff L, Exadaktylos A, Scholz J, Haaf P, Hamel C, Frey D, Delport K, Peacock WF, Freese M, DiSomma S, Todd J, Rentsch K, Bingisser R, Mueller C, Walter J, Twerenbold R, Nestelberger T, Boeddinghaus J, Badertscher P, du Fay de Lavallaz J, Puelacher C, Wildi K. Inflammatory Biomarkers and Clinical Judgment in the Emergency Diagnosis of Urgent Abdominal Pain. Clin Chem 2018; 65:302-312. [PMID: 30518662 DOI: 10.1373/clinchem.2018.296491] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 11/15/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND The early diagnosis of urgent abdominal pain (UAP) is challenging. Most causes of UAP are associated with extensive inflammation. Therefore, we hypothesized that quantifying inflammation using interleukin-6 and/or procalcitonin would provide incremental value in the emergency diagnosis of UAP. METHODS This was an investigator-initiated prospective, multicenter diagnostic study enrolling patients presenting to the emergency department (ED) with acute abdominal pain. Clinical judgment of the treating physician regarding the presence of UAP was quantified using a visual analog scale after initial clinical and physician-directed laboratory assessment, and again after imaging. Two independent specialists adjudicated the final diagnosis and the classification as UAP (life-threatening, needing urgent surgery and/or hospitalization for acute medical reasons) using all information including histology and follow-up. Interleukin-6 and procalcitonin were measured blinded in a central laboratory. RESULTS UAP was adjudicated in 376 of 1038 (36%) patients. Diagnostic accuracy for UAP was higher for interleukin-6 [area under the ROC curve (AUC), 0.80; 95% CI, 0.77-0.82] vs procalcitonin (AUC, 0.65; 95% CI, 0.62-0.68) and clinical judgment (AUC, 0.69; 95% CI, 0.65-0.72; both P < 0.001). Combined assessment of interleukin-6 and clinical judgment increased the AUC at presentation to 0.83 (95% CI, 0.80-0.85) and after imaging to 0.87 (95% CI, 0.84-0.89) and improved the correct identification of patients with and without UAP (net improvement in mean predicted probability: presentation, +19%; after imaging, +15%; P < 0.001). Decision curve analysis documented incremental value across the full range of pretest probabilities. A clinical judgment/interleukin-6 algorithm ruled out UAP with a sensitivity of 97% and ruled in UAP with a specificity of 93%. CONCLUSIONS Interleukin-6 significantly improves the early diagnosis of UAP in the ED.
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Affiliation(s)
- Tobias Breidthardt
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland; .,Department of Internal Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | | | | | | | - Katrin Burri-Winkler
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Hospital del Mar, Barcelona, Spain
| | | | | | | | - Julia Scholz
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
| | - Philip Haaf
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Cardiology, University Hospital, Basel, and University of Basel, Switzerland
| | - Christian Hamel
- Department of Visceral Surgery, University Hospital, Basel, and University of Basel, Switzerland.,Department of Visceral Surgery, Kliniken des Landkreises, Lörrach, Germany
| | - Daniel Frey
- Department of Visceral Surgery, University Hospital, Basel, and University of Basel, Switzerland.,Department of Surgery, Spital Wetzikon, Wetzikon, Switzerland
| | - Karen Delport
- Emergency Department, Kantonspital Baselland, Bruderholz, Switzerland
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Michael Freese
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Cardiology, University Hospital, Basel, and University of Basel, Switzerland
| | - Salvatore DiSomma
- Emergency Department, San Andrea Hospital, University Sapienza, Rome, Italy
| | - John Todd
- Singulex Inc., Clinical Research, Alameda, CA
| | - Katharina Rentsch
- Department of Laboratory Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Roland Bingisser
- Emergency Department, University Hospital, Basel, and University of Basel, Switzerland
| | - Christian Mueller
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Cardiology, University Hospital, Basel, and University of Basel, Switzerland
| | | | - Joan Walter
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Cardiology, University Hospital, Basel, and University of Basel, Switzerland
| | - Raphael Twerenbold
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland.,Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
| | - Thomas Nestelberger
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Jasper Boeddinghaus
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Patrick Badertscher
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Jeanne du Fay de Lavallaz
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Christian Puelacher
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
| | - Karin Wildi
- Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Medicine, University Hospital, Basel, and University of Basel, Switzerland
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Fong RY, Glen WSS, Mohamed Jamil AK, Tam WWS, Kowitlawakul Y. Comparison of the Emergency Severity Index versus the Patient Acuity Category Scale in an emergency setting. Int Emerg Nurs 2018; 41:13-18. [DOI: 10.1016/j.ienj.2018.05.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 03/13/2018] [Accepted: 05/11/2018] [Indexed: 01/06/2023]
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Parker CA, Liu N, Wu SX, Shen Y, Lam SSW, Ong MEH. Predicting hospital admission at the emergency department triage: A novel prediction model. Am J Emerg Med 2018; 37:1498-1504. [PMID: 30413365 DOI: 10.1016/j.ajem.2018.10.060] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 10/27/2018] [Accepted: 10/28/2018] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Emergency department (ED) overcrowding is a growing international patient safety issue. A major contributor to overcrowding is long wait times for inpatient hospital admission. The objective of this study is to create a model that can predict a patient's need for hospital admission at the time of triage. METHODS Retrospective observational study of electronic clinical records of all ED visits over ten years to a large urban hospital in Singapore. The data was randomly divided into a derivation set and a validation set. We used the derivation set to develop a logistic regression model that predicts probability of hospital admission for patients presenting to the ED. We tested the model on the validation set and evaluated the performance with receiver operating characteristic (ROC) curve analysis. RESULTS A total of 1,232,016 visits were included for final analysis, of which 38.7% were admitted. Eight variables were included in the final model: age group, race, postal code, day of week, time of day, triage category, mode of arrival, and fever status. The model performed well on the validation set with an area under the curve of 0.825 (95% CI 0.824-0.827). Increasing age, increasing triage acuity, and mode of arrival via private patient transport were most predictive of the need for admission. CONCLUSIONS We developed a model that accurately predicts admission for patients presenting to the ED using demographic, administrative, and clinical data routinely collected at triage. Implementation of the model into the electronic health record could help reduce the burden of overcrowding.
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Affiliation(s)
| | - Nan Liu
- Duke-NUS Medical School, National University of Singapore, Singapore; Health Services Research Centre, Singapore Health Services, Singapore.
| | - Stella Xinzi Wu
- Duke-NUS Medical School, National University of Singapore, Singapore.
| | - Yuzeng Shen
- Department of Emergency Medicine, Singapore General Hospital, Singapore.
| | - Sean Shao Wei Lam
- Duke-NUS Medical School, National University of Singapore, Singapore; Health Services Research Centre, Singapore Health Services, Singapore.
| | - Marcus Eng Hock Ong
- Duke-NUS Medical School, National University of Singapore, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore.
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Ghafarypour-Jahrom M, Taghizadeh M, Heidari K, Derakhshanfar H. Validity and Reliability of the Emergency Severity Index and Australasian Triage System in Pediatric Emergency Care of Mofid Children's Hospital in Iran. Bull Emerg Trauma 2018; 6:329-333. [PMID: 30402522 PMCID: PMC6215064 DOI: 10.29252/beat-060410] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: To evaluate the validity, reliability, sensitivity, and specificity of the Emergency Severity Index (ESI) and Australasian Triage System (ATS) for children visiting admitted to the emergency department (ED). Methods: This was a prospective study occurred in the Mofid children's Hospital in Iran from August 2017 to November 2018 and children had aged ≤14 years and presented at the ED with a medical symptom were considered eligible for participation. This study was divided into two phases: in the first phase, we determined the inter-rater reliability of ESI version 4 and ATS by triage nurses and pediatric residents. In the second phase, to analyze the validity, sensitivity, and specificity of each triage system. Reliability and agreement rates were measured using kappa statistics. Results: ESI showed inter-rater reliability with kappa of 0.65–0.92 (P<0.001) and ATS showed inter-rater reliability with kappa of 0.51–0.87 ESI had sensitivity ranged from 81% to 95% and specificity ranged from 73% to 86%. In addition, sensitivity ranged of the ATS were 80% to 95% and specificity ranged from 74% to 87%. Under triage and over triage occurred in 12% and 15% of patients respectively in ESI and 13% and 15% of patients respectively in ATS. Conclusion: The ESI and ATS both valid to triage children in the ED section of Mofid children's Hospital paediatric. Reliability of the ESI is good, moderate to good for the ATS.
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Affiliation(s)
| | - Mehrdad Taghizadeh
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Kamran Heidari
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hojat Derakhshanfar
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Nishi FA, Polak C, Cruz DDALMD. Sensitivity and specificity of the Manchester Triage System in risk prioritization of patients with acute myocardial infarction who present with chest pain. Eur J Cardiovasc Nurs 2018; 17:660-666. [DOI: 10.1177/1474515118777402] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The purpose of the Manchester Triage System is to clinically prioritize each patient seeking care in an emergency department. Patients with suspected acute myocardial infarction who have typical symptoms including chest pain should be classified in the highest priority groups, requiring immediate medical assistance or care within 10 min. As such, the Manchester Triage System should present adequate sensitivity and specificity. Aims: This study estimated the sensitivity and specificity of the Manchester Triage System in the triage of patients with chest pain related to the diagnosis of acute myocardial infarction, and the associations between the performance of the Manchester Triage System and selected variables. Methods: This was an observational, analytical, cross-sectional, retrospective study. The sensitivity and specificity of the Manchester Triage System were estimated by verifying the triage classification received by these patients and their established medical diagnoses. Results: The sample was composed of 10,087 triage episodes, in which 139 (1.38%) patients had a diagnosis of acute myocardial infarction. In 49 episodes, confirmation of medical diagnosis was not possible. The estimated sensitivity of the Manchester Triage System was 44.60% (36.18–53.27%) and the estimated specificity was 91.30% (90.73–91.85%). Of the 10,038 episodes in which the diagnosis of acute myocardial infarction was confirmed or excluded, 938 patients (9.34%) received an incorrect classification – undertriage or overtriage. Conclusion: This study showed that the specificity of the Manchester Triage System was very good. However, the low sensitivity based on the Manchester Triage System indicated that patients in high priority categories were undertriaged, leading to longer wait times and associated increased risks of adverse events.
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Kuriyama A, Ikegami T, Kaihara T, Fukuoka T, Nakayama T. Validity of the Japan Acuity and Triage Scale in adults: a cohort study. Emerg Med J 2018. [PMID: 29535086 DOI: 10.1136/emermed-2017-207214] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Japan Acuity and Triage Scale (JTAS) was developed based on Canadian Triage and Acuity Scale in 2012 and has been implemented in many Japanese EDs. We assessed the validity of JTAS by examining the association between JTAS triage levels and throughput and clinical outcomes in adult patients. METHODS We conducted a retrospective analysis of prospectively collected clinical data in the ED of a Japanese tertiary-care hospital. We included self-presenting patients who were ≥16 years of age and triaged between June 2013 and May 2014. We assessed the association between the triage level and overall admission and admission to the intensive care units (ICUs) with multivariable logistic regression analysis adjusted with patients' age and the time of visit and ED length of stay using the Kruskal-Wallis rank-sum test. We examined the predictive ability of JTAS for determining overall and ICU admission using receiver operating characteristic curves. RESULTS We included a total of 27 120 adult patients in our study. The OR for overall admission was greater with a higher triage level compared with the lowest urgency levels. ED length of stay was significantly longer with a higher JTAS level (p<0.001). The OR for ICU admission was greater in JTAS 1 (117.93 (95% CI 69.07 to 201.38)) and JTAS 2 (9.43 (95% CI 13.74 to 29.30)) compared with the lowest urgency levels. The areas under the curve for the predictive ability of JTAS for overall and ICU admission were 0.726 and 0.792, respectively. CONCLUSION Our study suggests an association of JTAS acuity with overall admission, ICU admission and ED length of stay, thereby demonstrating the predictive validity of JTAS.
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Affiliation(s)
- Akira Kuriyama
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan.,Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
| | - Tetsunori Ikegami
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toshie Kaihara
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toshio Fukuoka
- Emergency and Critical Care Center, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
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Kuriyama A, Urushidani S, Nakayama T. Five-level emergency triage systems: variation in assessment of validity. Emerg Med J 2017; 34:703-710. [PMID: 28751363 DOI: 10.1136/emermed-2016-206295] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 04/19/2017] [Accepted: 05/05/2017] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Triage systems are scales developed to rate the degree of urgency among patients who arrive at EDs. A number of different scales are in use; however, the way in which they have been validated is inconsistent. Also, it is difficult to define a surrogate that accurately predicts urgency. This systematic review described reference standards and measures used in previous validation studies of five-level triage systems. METHODS We searched PubMed, EMBASE and CINAHL to identify studies that had assessed the validity of five-level triage systems and described the reference standards and measures applied in these studies. Studies were divided into those using criterion validity (reference standards developed by expert panels or triage systems already in use) and those using construct validity (prognosis, costs and resource use). RESULTS A total of 57 studies examined criterion and construct validity of 14 five-level triage systems. Criterion validity was examined by evaluating (1) agreement between the assigned degree of urgency with objective standard criteria (12 studies), (2) overtriage and undertriage (9 studies) and (3) sensitivity and specificity of triage systems (7 studies). Construct validity was examined by looking at (4) the associations between the assigned degree of urgency and measures gauged in EDs (48 studies) and (5) the associations between the assigned degree of urgency and measures gauged after hospitalisation (13 studies). Particularly, among 46 validation studies of the most commonly used triages (Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System), 13 and 39 studies examined criterion and construct validity, respectively. CONCLUSION Previous studies applied various reference standards and measures to validate five-level triage systems. They either created their own reference standard or used a combination of severity/resource measures.
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Affiliation(s)
- Akira Kuriyama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan.,Department of General Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Seigo Urushidani
- Department of Emergency Medicine, Kurashiki Central Hospital, Kurashiki, Okayama, Japan
| | - Takeo Nakayama
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Japan
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Van Der Linden MC, Khursheed M, Hooda K, Pines JM, Van Der Linden N. Two emergency departments, 6000km apart: Differences in patient flow and staff perceptions about crowding. Int Emerg Nurs 2017; 35:30-36. [PMID: 28659247 DOI: 10.1016/j.ienj.2017.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Emergency department (ED) crowding is a worldwide public health issue. In this study, patient flow and staff perceptions of crowding were assessed in Pakistan (Aga Khan University Hospital (AKUH)) and in the Netherlands (Haaglanden Medical Centre Westeinde (HMCW)). Bottlenecks affecting ED patient flow were identified. METHODS First, a one-year review of patient visits was performed. Second, staff perceptions about ED crowding were collected using face-to-face interviews. Non-participant observation and document review were used to interpret the findings. RESULTS At AKUH 58,839 (160visits/day) and at HMCW 50,802 visits (140visits/day) were registered. Length of stay (LOS) at AKUH was significantly longer than at HMCW (279min (IQR 357) vs. 100min (IQR 152)). There were major differences in patient acuities, admission and mortality rates, indicating a sicker population at AKUH. Respondents from both departments experienced hampered patient flow on a daily basis, and perceived similar causes for crowding: increased patients' complexity, long treatment times, and poor availability of inpatient beds. CONCLUSION Despite differences in environment, demographics, and ED patient flow, respondents perceived similar bottlenecks in patient flow. Interventions should be tailored to specific ED and hospital needs. For both EDs, improving the outflow of boarded patients is essential.
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Affiliation(s)
| | - Munawar Khursheed
- Emergency Department, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Jesse M Pines
- Office for Clinical Practice Innovation, Departments of Emergency Medicine and Health Policy & Management, George Washington University, Washington, DC, USA
| | - Naomi Van Der Linden
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, Sydney, Australia
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Nishi FA, de Oliveira Motta Maia F, de Souza Santos I, de Almeida Lopes Monteiro da Cruz D. Assessing sensitivity and specificity of the Manchester Triage System in the evaluation of acute coronary syndrome in adult patients in emergency care: a systematic review. JBI DATABASE OF SYSTEMATIC REVIEWS AND IMPLEMENTATION REPORTS 2017; 15:1747-1761. [PMID: 28628525 DOI: 10.11124/jbisrir-2016-003139] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Triage is the first assessment and sorting process used to prioritize patients arriving in the emergency department (ED). As a triage tool, the Manchester Triage System (MTS) must have a high sensitivity to minimize the occurrence of under-triage, but must not compromise specificity to avoid the occurrence of overtriage. Sensitivity and specificity of the MTS can be calculated using the frequency of appropriately assigned clinical priority levels for patients presenting to the ED. However, although there are well established criteria for the prioritization of patients with suspected acute coronary syndrome (ACS), several studies have reported difficulties when evaluating patients with this condition. OBJECTIVE The objective of this review was to synthesize the best available evidence on assessing the sensitivity and specificity of the MTS for screening high-level priority adult patients presenting to the ED with ACS. METHOD The current review considered studies that evaluated the use of the MTS in the risk classification of adult patients in the ED. In this review, studies that investigated the priority level, as established by the MTS to screen patients under suspicion of ACS or the sensitivity and specificity of the MTS, for screening patients before the medical diagnosis of ACS were included. This review included both experimental and epidemiological study designs. RESULTS The results were presented in a narrative synthesis. Six studies were appraised by the independent reviewers. All appraised studies enrolled a consecutive or random sample of patients and presented an overall moderate methodological quality, and all of them were included in this review. A total of 54,176 participants were included in the six studies. All studies were retrospective. Studies included in this review varied in content and data reporting. Only two studies reported sensitivity and specificity values or all the necessary data to calculate sensitivity and specificity. The remaining four studies presented either a sensitivity analysis or the number of true positives and false negatives. However, these four studies were conducted considering only data from patients diagnosed with ACS. Sensitivity values were relatively uniform among the studies: 0.70-0.80. A specificity of 0.59 was reported in the study including only patients with non-traumatic chest pain. On the other hand, in the study that included patients with any complaint, the specificity of MTS to screen patients with ACS was 0.97. CONCLUSION The current review demonstrates that the MTS has a moderate sensitivity to evaluate patients with ACS. This may compromise time to treatment in the ED, an important variable in the prognosis of ACS. Atypical presentation of ACS, or high specificity, may also explain the moderate sensitivity demonstrated in this review. However, because of minimal data, it is not possible to confirm this hypothesis. It is difficult to determine the acceptable level of sensitivity or specificity to ensure that a certain triage system is safe.
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Affiliation(s)
- Fernanda Ayache Nishi
- 1University Hospital, University of São Paulo, São Paulo, Brazil 2The Brazilian Centre for Evidence-Informed Healthcare: a Joanna Briggs Institute Centre of Excellence, São Paulo, Brazil 3School of Medicine, University of São Paulo, São Paulo, Brazil 4School of Nursing, University of São Paulo, São Paulo, Brazil
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Cicolo EA, Ayache Nishi F, Ciqueto Peres HH, Cruz DDALMD. Effectiveness of the Manchester Triage System on time to treatment in the emergency department: a systematic review protocol. ACTA ACUST UNITED AC 2017; 15:889-898. [DOI: 10.11124/jbisrir-2016-003119] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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