Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France

Children accessing accident and emergency department for non-urgent consultations: A cross-sectional study about parents' use of primary care services

INTRODUCTION

Parents often take their children to the Paediatric Accident and Emergency Department (A&E) for non-urgent consultations rather than using community-based primary care services. This study describes the use of primary care services in parents taking their children to the A&E for non-urgent consultations.

METHODS

A cross-sectional study was conducted from July 2018 to June 2019, in a second-level Italian paediatric A&E of a tertiary-level children's academic research and hub hospital. Parents of children aged between 3 months and 6 years assigned with a white code at the triage were asked to complete a paper-and-pencil 40-item questionnaire after accessing the A&E for a non-urgent consultation.

RESULTS

The questionnaire was completed by the parents of 237 children (males 58 %; median age = 2.3 years). Overall, 48.1 % (n = 114) of the parents reported consulting 'often/always' the primary care paediatrician, mainly when their child was sick and for check-ups (n = 182, 76.8 %). However, only 7.2 % (n = 17) of the parents 'often/always' used any other health service in the community. Most of them (n = 191, 82 %) did not even know where the community health centre was located.

CONCLUSION

Parents accessing the A&E for non-urgent consultations should be better informed/educated on how to use community health services.

Reduction of Waiting Times and Patients Leaving Without Being Seen in the Tertiary Pediatric Emergency Department: A Comparative Observational Study

OBJECTIVES

Analyze the effectiveness of an intervention to reduce waiting time and patients leaving without being seen in the pediatric emergency department.

METHODS

A comparative observational study was carried out from November 2018 to April 2019.Patients aged 3 months to 17 years were included. The new organizational model consisted of a dedicated outpatients' clinic for nonurgent codes and a fast track for traumatic and surgical emergency cases.

RESULTS

The comparative group included 14,822, and the intervention group included 15,585 patients. The new organizational model significantly reduced the numbers of patients who left the ED without being seen from 12.9% to 5.9%.

CONCLUSIONS

This new organizational model in the pediatric emergency department could be successfully used to reduce overcrowding, waiting time, and the numbers of patients leaving without being seen. However, more needs to be done by the pediatric services in the community to reduce nonurgent accesses to the emergency department.

Development of Nurse-Sensitive, Emergency Department-Specific Quality Indicators Using a Modified Delphi Technique

BACKGROUND

There is no identified set of nursing-sensitive, emergency department (ED)-specific quality indicators.

PURPOSE

The purpose of this study was to address the gap in quality indicators specific to the emergency care environment and identify a list of nursing-sensitive, ED-specific quality indicators across ED populations and phases of the ED visit for further development and testing.

METHODS

A modified Delphi technique was used to reach initial consensus.

RESULTS

Four thematic groups were identified, and quality indicators within each were rank ordered. Of the 4 groups, 21 quality indicators were identified: triage (6) was ranked highest, followed by special populations (4), transitions of care (4), and medical/surgical (7).

CONCLUSIONS

Many of the recommended metrics were questionable because they are nonspecific to the ED setting or subject to influences in the emergency care environment. Some identified priorities for quality indicator development were unsupported; we recommend that alternate methodologies be used to identify critical areas of quality measurement.

Pediatric patients accessing Accident and Emergency Department (A&E) for non-urgent treatment: Why do parents take their children to the A&E?

INTRODUCTION

About 20-30% of children access the Pediatric Accident and Emergency Department (A&E) for non-urgent health care that should normally follow other health care paths. This study aimed to investigate why parents take their children to the A&E for non-urgent visits rather than using primary care services.

METHODS

A one-year cross-sectional study was conducted in a large pediatric A&E in Italy. A paper-and-pencil 40-item questionnaire was administered to parents of children aged between 3 months to 6 years who accessed the A&E for non-urgent visits between July 2018 and June 2019.

RESULTS

Parents of 238 children completed the questionnaire (mean age = 2.6 years; male 58%). The most common symptoms were fever (n = 105; 44.1%) and skin rash (n = 63; 26.5%); symptoms usually started more than 24 h earlier (n = 163; 69.4%). Reasons for accessing the A&E for non-urgent visits included the availability of rapid medical tests (n = 71; 29.8%), deterioration of the clinical conditions after the pediatrician's visit (n = 67; 28.2%), and the perceived need for urgent care (n = 65; 27.3%). Besides, 26.6% (n = 63) of parents reported not being able to contact their pediatrician before accessing A&E.

CONCLUSION

Parents may need further education to distinguish between urgent and non-urgent pediatric health conditions.

Avoidable emergency department visits: a starting point

Objective

To better characterize and understand the nature of a very conservative definition of 'avoidable' emergency department (ED) visits in the United States to provide policymakers insight into what interventions can target non-urgent ED visits.

Design/setting

We performed a retrospective analysis of a very conservative definition of 'avoidable' ED visits using data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011.

Participants

We examined a total of 115 081 records, representing 424 million ED visits made by patients aged 18-64 years who were seen in the ED and discharged home.

Main outcome measures

We defined 'avoidable' as ED visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home.

Results

In total, 3.3% (95% CI: 3.0-3.7) of all ED visits were 'avoidable.' The top five chief complaints included toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. Alcohol abuse, dental disorders and depressive disorders were among the top three ICD-9 discharge diagnoses. Alcohol-related disorders and mood disorders accounted for 6.8% (95% CI: 5.7-8.0) of avoidable visits, and dental disorders accounted for 3.9% (95% CI: 3.0-4.8) of CCS-grouped discharge diagnoses.

Conclusions

A significant number of 'avoidable' ED visits were for mental health and dental conditions, which the ED is not fully equipped to treat. Our findings provide a better understanding of what policy initiatives could potentially reduce these 'avoidable' ED visits to address the gaps in our healthcare system, such as increased access to mental health and dental care.

Effectiveness of Interventions for Prevention of Road Traffic Injuries in Iran and Some Methodological Issues: A Systematic Review

Objective

To review the effectiveness of Road Traffic Injuries (RTIs) interventions implemented for prevention of RTIs in Iran and to introduce some methodological issues.

Methods

Required data in this systematic review study were collected through searching the following key words: "Road Traffic Injuries", "Road Traffic accidents", "Road Traffic crashes", "prevention", and Iran in PubMed, Cochrane Library electronic databases, Google Scholar, Scopus, MagIran, SID and IranMedex. Some of the relevant journals and web sites searched manually. Reference lists of the selected articles were also checked. Gray literature search and expert contact was also conducted.

Results

Out of 569 retrieved articles, finally 8 articles included. Among the included studies the effectiveness of 10 interventions were assessed containing: seat belt, enforcements of laws and legislations, educational program, wearing helmet, Antilock Braking System (ABS), motorcyclists' penalty enforcement, pupil liaisons' education, provisional driver licensing, Road bumps and traffic improvement's plans. In 7 studies (9 interventions) reduction of RTIs rate were reported. Decreased rate of mortality from RTIs were reported in three studies. Only one study had mentioned financial issue (Anti-lock Brake System intervention). Inadequate data sources, inappropriate selection of statistical index and not mention about the control of Confounding Variables (CV), the most common methodological issues were.

Conclusion

The results of most interventional studies conducted in Iran supported the effect of the interventions on reduction of RTIs. However due to some methodological or reporting shortcoming the results of these studies should be interpreted cautiously.

Insertion site assessment of peripherally inserted central catheters: Inter-observer agreement between nurses and inpatients

INTRODUCTION

Many patients are discharged from hospital with a peripherally inserted central catheter in place. Monitoring the peripherally inserted central catheter insertion site for clinical and research purposes is important for identifying complications, but the extent to which patients can reliably report the condition of their catheter insertion site is uncertain. The aim of this study was to assess the inter-observer agreement between nurses and patients when assessing a peripherally inserted central catheter site.

METHODS

The study was based on inpatients who were enrolled in a single-centre, randomised controlled trial comparing four different dressing and securement devices for peripherally inserted central catheter sites. A seven-item peripherally inserted central catheter site assessment tool, containing questions about the condition of the dressing and the insertion site, was developed. Assessment was conducted once by the research nurse and, within a few minutes, independently by the patient. Proportions of agreement and Cohen's kappa were calculated.

RESULTS

In total, 73 patients agreed to participate. Overall, percentage agreement ranged from 83% to 100% (kappa = .65-.82). For important clinical signs (redness, swelling, ooze, pus and tracking), there were high levels of percentage agreement (99%-100%).

CONCLUSION

The high level of agreement between nurse/patient pairs make the instrument useful for assessing peripherally inserted central catheter-associated signs of localised infection, allergic or irritant dermatitis or dressing dislodgement in a community setting.

Why do patients with minor complaints choose emergency departments and does satisfaction with primary care services influence their decisions?

AimTo identify the reasons why patients with minor complaints choose emergency departments (EDs) as a first contact of care and whether dissatisfaction with primary care services influences their decisions.

METHODS

In this study, a self-completed survey called EUROPEP was given to 535 outpatients who were admitted to the Bursa Yuksek Ihtisas Training and Research Hospital in Bursa and examined in the green zone in July 2015. Patients were asked about their complaints and why they preferred EDs as a first contact of care.

RESULTS

EDs were the first contact of care in 87.8% of cases. In all, 9% of patients registered to family physicians who were working outside the city of Bursa. There was no relationship between patient satisfaction and the number of previous visits to EDs in last 12 months (P=0.09). The main reasons for admitting to the emergency services were feeling excessive pain (20.4%), perception of urgency (14.5%) and that the family doctor services were closed outside working hours (13.2%). The mean patient satisfaction with family practice offices was calculated to be 68.1%.

CONCLUSIONS

The frequency of admission to EDs as a first contact of care was extremely high in the absence of a referral system. Patients who did not have family doctors in the settlement where they live put an extra burden on the EDs. Overall, patient satisfaction with their GPs did not influence the number of visits to EDs but accessibility remains a big challenge.

Triage quality control is missing tools-a new observation technique for ED quality improvement

Objective

Correct assessment of patient urgency is critical to ensuring patient safety in emergency departments (EDs). Although significant time and effort have been devoted to developing triage systems, less attention has been paid to the development of quality control. The aim of this study is to introduce and test observation technique, which enables identifying of patient groups at risk of erroneous assessment in triage. The introduced technique is aimed to be less laborious to use than existing triage quality control methods.

Design

The study developed an observation technique for identifying patients with possible erroneous assessments in triage. Data sample for the observation technique is carried out with survey form filled in by nurse.

Setting

Hospital ED with ~74 000 patient visits annually.

Participants

Consecutive adult patients in an ED for baseline study period of 14 days (1774 patients) in 2010 and control study period of 4 days (541 patients) in 2012.

Intervention

Triage observation technique for continuous improvement of triage performance.

Main Outcome Measures

Primary measures of triage improvement were triage accuracy and nurses' ability to predict patient admissions.

Results

With the observation technique the ED staff was able to identify patient groups at risk for erroneous triage. Under-triage related mostly to patients with chest pain, shortness of breath, collapse, stomach pain and infections. Instead injures and muscular skeletal symptoms were seldom undertriaged even though they are common.

Conclusions

EDs can control triage quality with simple observation technique. The usability of observation technique and triage quality improvement process were good.

Coping behavior and risk and resilience stress factors in French regional emergency medicine unit workers: a cross-sectional survey

The Emergency Department (ED) has the highest workload in a hospital, offering care to patients in their most acute state of illness, as well as comforting their families and tending to stressful situations of the physical and psychological areal. Method. A cross-sectional survey of 366 Emergency Unit staff members including medical doctors, medical residents, medical nurses and ward aids, was undergone. Study participants came from four periphery hospitals in the Moselle Department of Eastern France with similar workforce and daily patient loads statistics. The instruments used were the Perceived Stress Scale PSS-10 and the Brief COPE questionnaire. Conclusions. Perceived work overload and overall stress is strongly related to work hours and tend to have a stronger influence on doctors than on the nursing staff. Substance use is a common coping method for medical interns, consistent with prior research. The regular assessment of the ED staff perception of stress and stress related factors is essential to support organizational decisions in order to promote a better work environment and better patient care.

The effect of nurses' preparedness and nurse practitioner status on triage call management in primary care: A secondary analysis of cross-sectional data from the ESTEEM trial

Background

Nurse-led telephone triage is increasingly used to manage demand for general practitioner consultations in UK general practice. Previous studies are equivocal about the relationship between clinical experience and the call outcomes of nurse triage. Most research is limited to investigating nurse telephone triage in out-of-hours settings.

Objective

To investigate whether the professional characteristics of primary care nurses undertaking computer decision supported software telephone triage are related to call disposition.

Design

Questionnaire survey of nurses delivering the nurse intervention arm of the ESTEEM trial, to capture role type (practice nurse or nurse practitioner), prescriber status, number of years’ nursing experience, graduate status, previous experience of triage, and perceived preparedness for triage.

Our main outcome was the proportion of triaged patients recommended for follow-up within the practice (call disposition), including all contact types (face-to-face, telephone or home visit), by a general practitioner or nurse.

Settings

15 general practices and 7012 patients receiving the nurse triage intervention in four regions of the UK.

Participants

45 nurse practitioners and practice nurse trained in the use of clinical decision support software.

Methods

We investigated the associations between nursing characteristics and triage call disposition for patient ‘same-day’ appointment requests in general practice using multivariable logistic regression modelling.

Results

Valid responses from 35 nurses (78%) from 14 practices: 31/35 (89%) had ≥10 years’ experience with 24/35 (69%) having ≥20 years. Most patient contacts (3842/4605; 86%) were recommended for follow-up within the practice. Nurse practitioners were less likely to recommend patients for follow-up odds ratio 0.19, 95% confidence interval 0.07; 0.49 than practice nurses. Nurses who reported that their previous experience had prepared them less well for triage were more likely to recommend patients for follow-up (OR 3.17, 95% CI 1.18–5.55).

Conclusion

Nurse characteristics were associated with disposition of triage calls to within practice follow-up. Nurse practitioners or those who reported feeling ‘more prepared’ for the role were more likely to manage the call definitively. Practices considering nurse triage should ensure that nurses transitioning into new roles feel adequately prepared. While standardised training is necessary, it may not be sufficient to ensure successful implementation.

Triage at the Emergency Department: association between triage levels and patient outcome

AbstractOBJECTIVEIdentify association between sociodemographic, clinical and triage categories with protocol outcomes developed at Hospital São Paulo (HSP).METHODSRetrospective cohort study conducted with patients older than 18 years submitted to the triage protocol in August 2012. Logistic regression was used to associate the risk categories to outcomes (p-value ≤0,05).RESULTSMen with older age and those treated in clinical specialties had higher rates of hospitalization and death. Patients in the high-priority group had hospitalization and mortality rates five and 10.6 times, respectively (p < 0.0001).CONCLUSIONThe high-priority group experienced higher hospitalization and mortality rates. The protocol was able to detect patients with more urgent conditions and to identify risk factors for hospitalization and death.

Inter-rater Reliability of Triages Performed by the Electronic Triage System

OBJECTIVE

To examine the inter-rater reliability of triages performed by the Electronic Triage System (ETS) which has recently developed and used in hospital emergency department (ED).

METHODS

This cross-sectional study was conducted prospectively and studied 408 visitors of Tabriz Imam Reza hospital's ED. The variables of interest were age, sex, nurse-assigned triage category, physician-assigned triage category, disease type (trauma, non-trauma), and the referred room within the ED. Cohen's un-weighted kappa, linear weighted kappa, and quadratic weighted kappa were used to describe the reliability.

RESULTS

Un-weighted kappa observed to be 0.186 (95% CI: 0.123-0.249). Linear weighted kappa observed as 0.317 (95% CI: 0.251-0.384) and quadratic weighted kappa as 0.462 (95% CI: 0.336-0.589). In general, low agreement was seen between the triage nurses and ED physicians. For trauma patients and for those who were referred to the cardiopulmonary resuscitation room (CPR), all three types of kappa were higher than other visitors of the ED.

CONCLUSION

Inter-rater reliability of the triages performed by the ETS observed as ranging from poor to moderate. Implementing interventions that would create a common language between nurses and physicians about the triage of the ED visitors seems necessary. The more agreement on the triage of trauma and CPR patients might be due to their condition and the more attention to them.

A clinical prediction model to identify patients at high risk of death in the emergency department

Purpose

Rapid assessment and intervention is important for the prognosis of acutely ill patients admitted to the emergency department (ED). The aim of this study was to prospectively develop and validate a model predicting the risk of in-hospital death based on all available information available at the time of ED admission and to compare its discriminative performance with a non-systematic risk estimate by the triaging first health-care provider.

Methods

Prospective cohort analysis based on a multivariable logistic regression for the probability of death.

Results

A total of 8,607 consecutive admissions of 7,680 patients admitted to the ED of a tertiary care hospital were analysed. Most frequent APACHE II diagnostic categories at the time of admission were neurological (2,052, 24 %), trauma (1,522, 18 %), infection categories [1,328, 15 %; including sepsis (357, 4.1 %), severe sepsis (249, 2.9 %), septic shock (27, 0.3 %)], cardiovascular (1,022, 12 %), gastrointestinal (848, 10 %) and respiratory (449, 5 %). The predictors of the final model were age, prolonged capillary refill time, blood pressure, mechanical ventilation, oxygen saturation index, Glasgow coma score and APACHE II diagnostic category. The model showed good discriminative ability, with an area under the receiver operating characteristic curve of 0.92 and good internal validity. The model performed significantly better than non-systematic triaging of the patient.

Conclusions

The use of the prediction model can facilitate the identification of ED patients with higher mortality risk. The model performs better than a non-systematic assessment and may facilitate more rapid identification and commencement of treatment of patients at risk of an unfavourable outcome.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-015-3737-x) contains supplementary material, which is available to authorized users.

Reasons for non-urgent presentations to the emergency department in Saudi Arabia

BACKGROUND

The majority of patients who attend emergency departments (EDs) in Saudi Arabia have non-urgent problems, resulting in overcrowding, excessive waiting times and delayed care for more acutely ill patients. The purpose of this research was to examine the reasons for non-urgent visits to a Saudi ED and factors associated with patient perceptions of urgency.

METHODS

We administered a survey to 350 consecutively presenting Canadian Triage and Acuity Scale (CTAS) IV or V adult patients at a large tertiary ED in Riyadh region, Saudi Arabia, during 25 days of data collection in March 2013.

RESULTS

Over half of the sample usually visited the ED to access healthcare. The most common reasons for attending the ED were not having a regular healthcare provider (63%), being able to receive care on the same day (62%), and the convenience of and access to medical care 24/7 (62%). Approximately two-thirds of CTAS V patients and one-third of CTAS IV patients believed their conditions were more urgent than their triage nurse rating.

CONCLUSION

Multiple factors influence non-urgent visits to the ED in the Saudi context including insufficient community awareness of the role of the ED and perceived lack of access to primary healthcare services.

The cognitive processes underpinning clinical decision in triage assessment: a theoretical conundrum?

High quality clinical decision-making (CDM) has been highlighted as a priority across the nursing profession. Triage nurses, in the Accident and Emergency (A&E) department, work in considerable levels of uncertainty and require essential skills including: critical thinking, evaluation and decision-making. The content of this paper aims to promote awareness of how triage nurses make judgements and decisions in emergency situations. By exploring relevant literature on clinical judgement and decision-making theory, this paper demonstrates the importance of high quality decision-making skills underpinning the triage nurse's role. Having an awareness of how judgements and decisions are made is argued as essential, in a time where traditional nurse boundaries and responsibilities are never more challenged. It is hoped that the paper not only raises this awareness in general but also, in particular, engages the triage nurse to look more critically at how they make their own decisions in their everyday practice.