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Berendsen Russell S, Seimon RV, Dixon E, Murphy M, Vukasovic M, Bohlken N, Taylor S, Cooper Z, Scruton J, Jain N, Dinh MM. Applying Sydney Triage to Admission Risk Tool (START) to improve patient flow in emergency departments: a multicentre randomised, implementation study. BMC Emerg Med 2024; 24:39. [PMID: 38454324 PMCID: PMC10921805 DOI: 10.1186/s12873-024-00956-5] [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: 09/22/2023] [Accepted: 02/26/2024] [Indexed: 03/09/2024] Open
Abstract
BACKGROUND To determine the effectiveness of applying the Sydney Triage to Admission Risk Tool (START) in conjunction with senior early assessment in different Emergency Departments (EDs). METHODS This multicentre implementation study, conducted in two metropolitan EDs, used a convenience sample of ED patients. Patients who were admitted, after presenting to both EDs, and were assessed using the existing senior ED clinician assessment, were included in the study. Patients in the intervention group were assessed with the assistance of START, while patients in the control group were assessed without the assistance of START. Outcomes measured were ED length of stay and proportion of patients correctly identified as an in-patient admission by START. RESULTS A total of 773 patients were evaluated using the START tool at triage across both sites (Intervention group n = 355 and control group n = 418 patients). The proportion of patients meeting the 4-hour length of stay thresholds was similar between the intervention and control groups (30.1% vs. 28.2%; p = 0.62). The intervention group was associated with a reduced ED length of stay when compared to the control group (351 min, interquartile range (IQR) 221.0-565.0 min versus 383 min, IQR 229.25-580.0 min; p = 0.85). When stratified into admitted and discharged patients, similar results were seen. CONCLUSION In this extension of the START model of care implementation study in two metropolitan EDs, START, when used in conjunction with senior early assessment was associated with some reduced ED length of stay.
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Affiliation(s)
- Saartje Berendsen Russell
- Emergency Department, RPA Green Light Institute, Royal Prince Alfred Hospital, Missenden Road, 2050, Camperdown, NSW, Australia.
| | - Radhika V Seimon
- Emergency Department, RPA Green Light Institute, Royal Prince Alfred Hospital, Missenden Road, 2050, Camperdown, NSW, Australia
| | - Emma Dixon
- Emergency Department, Westmead Hospital, Westmead, NSW, Australia
| | - Margaret Murphy
- Emergency Department, Westmead Hospital, Westmead, NSW, Australia
| | | | - Nicole Bohlken
- Emergency Department, Westmead Hospital, Westmead, NSW, Australia
| | - Sharon Taylor
- Emergency Department, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Zoe Cooper
- Emergency Department, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Jennifer Scruton
- Emergency Department, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Nitin Jain
- Emergency Department, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Michael M Dinh
- Emergency Department, RPA Green Light Institute, Royal Prince Alfred Hospital, Missenden Road, 2050, Camperdown, NSW, Australia
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Salvato M, Solbiati M, Bosco P, Casazza G, Binda F, Iotti M, Calegari J, Laquintana D, Costantino G. Prospective comparison of AMB, GAP AND START scores and triage nurse clinical judgement for predicting admission from an ED: a single-centre prospective study. Emerg Med J 2021; 39:897-902. [PMID: 34969662 DOI: 10.1136/emermed-2020-210814] [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: 10/27/2020] [Accepted: 12/14/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND It is postulated that early determination of the need for admission can improve flow through EDs. There are several scoring systems which have been developed for predicting patient admission at triage, although they have not been directly compared. In addition, it is not known if these scoring systems perform better than clinical judgement. Therefore, the aim of this study was to validate existing tools in predicting hospital admission during triage and then compare them with the clinical judgement of triage nurses. METHODS To conduct this prospective, single-centre observational study, we enrolled consecutive adult patients who presented between 30 September 2019 and 25 October 2019 at the ED of a large teaching hospital in Milan, Italy. For each patient, triage nurses recorded all of the variables needed to perform Ambulatory (AMB), Glasgow Admission Prediction (GAP) and Sydney Triage to Admission Risk Tool (START) scoring. The probability of admission was estimated by the triage nurses using clinical judgement and expressed as a percentage from 0 to 100 with intervals of 5. Nurse estimates were dichotomised for analysis, with ≥50% likelihood being a prediction of admission. Receiver operating characteristic curves were generated for accuracy of the predictions. Area under the curve (AUC) with 95% CI for each of the scores and for the nursing judgements was also calculated. RESULTS A total of 1710 patients (844 men; median age, 54 years (IQR: 34-75)) and 35 nurses (15 men; median age, 37 years (IQR: 33-48)) were included in this study. Among these patients, 310 (18%) were admitted to hospital from the ED. AUC values for AMB, GAP and START scores were 0.77 (95% CI: 0.74 to 0.79), 0.72 (95% CI: 0.69 to 0.75) and 0.61 (95% CI: 0.58 to 0.64), respectively. The AUC for nurse clinical judgement was 0.86 (95% CI: 0.84 to 0.89). CONCLUSION AMB, GAP and START scores provided moderate accuracy in predicting patient admission. However, all of the scores were significantly worse than the clinical judgement of the triage nurses.
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Affiliation(s)
- Mauro Salvato
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Monica Solbiati
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Paola Bosco
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,UOC Direzione delle Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giovanni Casazza
- Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
| | - Filippo Binda
- UOC Direzione delle Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Iotti
- UO Comparto Operatorio, Columbus Clinic Center, Milan, Italy
| | - Jessica Calegari
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Dario Laquintana
- UOC Direzione delle Professioni Sanitarie, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giorgio Costantino
- UOC Pronto Soccorso e Medicina d'Urgenza, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Dipartimento di Scienze Cliniche e di Comunità, Università degli Studi di Milano, Milan, Italy
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Elias TCN, Bowen J, Hassanzadeh R, Lasserson DS, Pendlebury ST. Factors associated with admission to bed-based care: observational prospective cohort study in a multidisciplinary same day emergency care unit (SDEC). BMC Geriatr 2021; 21:8. [PMID: 33407210 PMCID: PMC7788859 DOI: 10.1186/s12877-020-01942-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 12/01/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The development of ambulatory emergency care services, now called 'Same Day Emergency Care' (SDEC) has been advocated to provide sustainable high quality healthcare in an ageing population. However, there are few data on SDEC and the factors associated with successful ambulatory care in frail older people. We therefore undertook a prospective observational study to determine i) the clinical characteristics and frailty burden of a cohort in an SDEC designed around the needs of older patients and ii) the factors associated with hospital admission within 30-days after initial assessment. METHODS The study setting was the multidisciplinary Abingdon Emergency Medical Unit (EMU) located in a community hospital and led by a senior interface physician (geriatrician or general practitioner). Consecutive patients from August-December 2015 were assessed using a structured paper proforma including cognitive/delirium screen, comorbidities, functional, social, and nutritional status. Physiologic parameters were recorded. Illness severity was quantified using the Systemic Inflammatory Response Syndrome (SIRS> 1). Factors associated with hospitalization within 30-days were determined using multivariable logistic regression. RESULTS Among 533 patients (median (IQR) age = 81 (68-87), 315 (59%) female), 453 (86%) were living at home but 283 (54%) required some form of care and 299 (56%) had Barthel< 20. Falls, urinary incontinence and dementia affected 81/189 (43%), 50 (26%) and 40 (21%) of those aged > 85 years." Severe illness was present in 148 (28%) with broadly similar rates across age groups. Overall, 210 (39%) patients had a hospital admission within 30-days with higher rates in older patients: 96 (87%) of < 65 years remained on an ambulatory pathway versus only 91 (48%) of ≥ 85 years (p < 0.0001). Factors independently associated with hospital admission were severe illness (SIRS/point, OR = 1.46,95% CI = 1.15-1.87, p = 0.002) and markers of frailty: delirium (OR = 11.28,3.07-41.44, p < 0.0001), increased care needs (OR = 3.08,1.55-6.12, p = 0.001), transport requirement (OR = 1.92,1.13-3.27), and poor nutrition (OR = 1.13-3.79, p = 0.02). CONCLUSIONS Even in an SDEC with a multidisciplinary approach, rates of hospital admission in those with severe illness and frailty were high. Further studies are required to understand the key components of hospital bed-based care that need to be replicated by models delivering acute frailty care closer to home, and the feasibility, cost-effectiveness and patient/carer acceptability of such models.
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Affiliation(s)
- Tania C N Elias
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, and the University of Oxford, Wolfson Building, Oxford, OX3 9DU, England.,Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Jordan Bowen
- Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Royah Hassanzadeh
- Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England
| | - Daniel S Lasserson
- PIONEER Health Data Research Hub, Institute for Applied Health Research, University of Birmingham, Birmingham, B15 2TT, England.,Department of Acute Medicine, City Hospital, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, B18 7QH, England
| | - Sarah T Pendlebury
- Wolfson Centre for Prevention of Stroke and Dementia, Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, and the University of Oxford, Wolfson Building, Oxford, OX3 9DU, England. .,Departments of Acute Internal Medicine and Geratology, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford, OX3 9DU, England. .,NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, OX3 9DU, England.
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Ebker-White A, Bein KJ, Berendsen Russell S, Dinh MM. The Sydney triage to admission risk tool (START) to improve patient flow in an emergency department: a model of care implementation pilot study. BMC Emerg Med 2019; 19:79. [PMID: 31805874 PMCID: PMC6896669 DOI: 10.1186/s12873-019-0290-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 11/12/2019] [Indexed: 11/18/2022] Open
Abstract
Background The Sydney Triage to Admission Risk Tool (START) is a validated clinical analytics tool designed to estimate the probability of in-patient admission based on Emergency Department triage characteristics. Methods This was a single centre pilot implementation study using a matched case control sample of patients assessed at ED triage. Patients in the intervention group were identified at triage by the START tool as likely requiring in-patient admission and briefly assessed by an ED Consultant. Bed management were notified of these patients and their likely admitting team based on senior early assessment. Matched controls were identified on the same day of presentation if they were admitted to the same in-patient teams as patients in the intervention group and same START score category. Outcomes were ED length of stay and proportion of patients correctly classified as an in-patient admission by the START tool. Results One hundred and thirteen patients were assessed using the START-based model of care. When compared with matched control patients, this intervention model of care was associated with a significant reduction in ED length of stay [301 min (IQR 225–397) versus 423 min (IQR 297–587) p < 0.001] and proportion of patients meeting 4 h length of stay thresholds increased from 24 to 45% (p < 0.001). Conclusion In this small pilot implementation study, the START tool, when used in conjunction with senior early assessment was associated with a reduction in ED length of stay. Further controlled studies are now underway to further examine its utility across other ED settings.
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Affiliation(s)
- Anja Ebker-White
- Emergency Department, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW, Sydney, 2050, Australia
| | - Kendall J Bein
- Emergency Department, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW, Sydney, 2050, Australia.,RPA Green Light Institute, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia
| | - Saartje Berendsen Russell
- Emergency Department, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW, Sydney, 2050, Australia.,RPA Green Light Institute, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia
| | - Michael M Dinh
- Emergency Department, Royal Prince Alfred Hospital, Missenden Road, Camperdown NSW, Sydney, 2050, Australia. .,RPA Green Light Institute, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW, 2050, Australia.
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Accuracy of National Early Warning Score 2 (NEWS2) in Prehospital Triage on In-Hospital Early Mortality: A Multi-Center Observational Prospective Cohort Study. Prehosp Disaster Med 2019; 34:610-618. [PMID: 31648657 DOI: 10.1017/s1049023x19005041] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION In cases of mass-casualty incidents (MCIs), triage represents a fundamental tool for the management of and assistance to the wounded, which helps discriminate not only the priority of attention, but also the priority of referral to the most suitable center. HYPOTHESIS/PROBLEM The objective of this study was to evaluate the capacity of different prehospital triage systems based on physiological parameters (Shock Index [SI], Glasgow-Age-Pressure Score [GAP], Revised Trauma Score [RTS], and National Early Warning Score 2 [NEWS2]) to predict early mortality (within 48 hours) from the index event for use in MCIs. METHODS This was a longitudinal prospective observational multi-center study on patients who were attended by Advanced Life Support (ALS) units and transferred to the emergency department (ED) of their reference hospital. Collected were: demographic, physiological, and clinical variables; main diagnosis; and data on early mortality. The main outcome variable was mortality from any cause within 48 hours. RESULTS From April 1, 2018 through February 28, 2019, a total of 1,288 patients were included in this study. Of these, 262 (20.3%) participants required assistance for trauma and injuries by external agents. Early mortality within the first 48 hours due to any cause affected 69 patients (5.4%). The system with the best predictive capacity was the NEWS2 with an area under the curve (AUC) of 0.891 (95% CI, 0.84-0.94); a sensitivity of 79.7% (95% CI, 68.8-87.5); and a specificity of 84.5% (95% CI, 82.4-86.4) for a cut-off point of nine points, with a positive likelihood ratio of 5.14 (95% CI, 4.31-6.14) and a negative predictive value of 98.7% (95% CI, 97.8-99.2). CONCLUSION Prehospital scores of the NEWS2 are easy to obtain and represent a reliable test, which make it an ideal system to help in the initial assessment of high-risk patients, and to determine their level of triage effectively and efficiently. The Prehospital Emergency Medical System (PhEMS) should evaluate the inclusion of the NEWS2 as a triage system, which is especially useful for the second triage (evacuation priority).
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Rabin E. Admission prediction rules: some limited promise, but far from proven. Emerg Med J 2018; 35:462-463. [DOI: 10.1136/emermed-2018-207759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2018] [Indexed: 11/04/2022]
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