Effect of a Triage Educational Intervention on Nurses' Knowledge and the Efficiency of Urgent Care in Saudi Arabia.

Introduction: The importance of early recognition and treatment of Sepsis has been emphasized over the last several years. In an attempt to better prioritize these patients, the Canadian Triage and Acuity Scale (CTAS) revised the adult temperature modifier after 2008 to define fever as 38.0C or higher and apply SIRS criteria, appearance and immunocompromise to assign a CTAS level of 2, 3, or 4. Prior to 2008, the fever threshold was defined as 38.5C and SIRS criteria were not included. This study looks to see if these changes increased the sensitivity of the temperature modifier. Methods: This study is a retrospective cohort analysis of patients presenting with a temperature of <36.0C or >38.0C to six Edmonton-area EDs in calendar years 2008 (n=26181) and 2012 (n=51622). Outcomes of interest included the temperature modifier predicted score and the actual assigned CTAS score. Data was extracted from the HASS/iSoft EDIS database including: presenting complaint, vital signs, CTAS score, and applied CTAS modifier to generate a before and after comparison of the actual and theoretical impact of temperature modifier revisions on the CTAS score, for both time periods. Results: Applying the pre-2008 temperature modifier to the 2008 patient cohort assigned 11.5% to CTAS 2, 39.8% to CTAS 3, and 33.3% to CTAS 4. Applying the post-2008 revised temperature modifier assigned 22.2% CTAS 2, 41.9% CTAS 3, and 27.6% CTAS 4. Carrying out the same analysis on the 2012 patients pre- results were 12.4% CTAS 2, 46.4% CTAS 3, 30.2% CTAS 4; and the post results were 21% CTAS 2, 47.7% CTAS 3, and 25% CTAS 4. Differences between pre- and post-results were statistically significant (p<0.0001) in both years. The actual triage scores in 2012 were 18.7% CTAS 2 indicating the temperature modifier was not always correctly applied and 50.6% CTAS 3 as other modifiers were sometimes applied. Conclusion: There was a significant increase in sensitivity following the post 2008 revisions to the CTAS temperature modifier when applied to two large ED patient cohorts. The differences between theoretical and actual CTAS scores was less dramatic as nurses were able to apply other first order or special modifiers to assign an appropriate score. Further analysis will be carried out to determine the impact of the temperature modifier revisions on time to antibiotic and admission rates.

The Predictors of Workload in the Emergency Room (POWER) study, published in 2009 using data from 2003, examined the workload of emergency physicians using the Canadian Triage and Acuity Scale (CTAS) as a surrogate marker. Many hospitals use a case-mix formula incorporating annual census and POWER's study data to determine staffing levels. However, significant changes in emergency medicine have occurred since its publication, including the implementation of electronic health record systems, increased patient complexity, real-time dictation software, and human health resource challenges due to the COVID-19 pandemic. In this study we aimed to quantify the time required to perform tasks during the care of ambulatory emergency department (ED) patients. Our secondary objective was to stratify these times based on CTAS and clinician factors. We conducted a prospective observational time-motion study in the urgent care section of a tertiary-care, academic ED with 90,000 visits annually, 70% of which are ambulatory. Research assistants shadowed physicians on two 8-hour shifts daily (8 am-12 am) from July 12-August 14, 2022, tracking the time taken by physicians to perform tasks. We calculated aggregate task times per patient. We observed 1,204 patient encounters over 65 shifts by 37 unique physicians. The mean treatment time was 21.6 minutes (95% confidence interval [CI] 19.9 - 23.3) for ambulatory CTAS 2 patients; 22.5 minutes (95% CI 21.2 - 23.6) for CTAS 3 patients; 19.7 minutes (95% CI 17.9 - 21.6) for CTAS 4 patients; and 17.4 minutes (95% CI 14.9 - 19.9) for CTAS 5 patients. Compared to the previous 2003 POWER study data, CTAS 4 and 5 patient assessment times took 31% and 58% longer, respectively. Total assessment time by CTAS was statistically significant only comparing CTAS 5 patients to all others (P = .02). Physicians who dictated their charts spent 34% less time (2.1 minutes per patient) charting than those who typed them. The average time to see an ambulatory ED patient was 21.7 minutes. Low-acuity urgent care patients take longer to assess now than 20 years ago. The CTAS alone is a poor marker of workload for ambulatory patients, necessitating a reassessment of staffing and compensation formulas.

Introduction Unplanned return visits (URVs) to the emergency department (ED) within 72 hours are an important quality indicator in emergency medicine, linked to patient safety and the quality of initial care. This study examines whether the Canadian Triage and Acuity Scale (CTAS) category at the initial visit predicts the likelihood of hospital admission upon URV. Methods A retrospective analysis was conducted over a 12-month period at a tertiary care teaching hospital. URVs were defined as registrations within 72 hours of an initial ED discharge, excluding planned returns. Data were extracted from electronic health records, including demographics, CTAS category, disposition, and admission status. Statistical analyses included Pearson correlation, linear regression, and Fisher's exact test to examine relationships between CTAS and admission risk. Statistical significance was set at p < 0.05. Results Of 57,025 ED attendances, 82.1% (46,793) were discharged, of whom 7.6% (3,566) returned within 72 hours. Among URVs, 14.9% (532) resulted in admission. Admission rates on return varied by initial CTAS level, ranging from 23.1% (CTAS 1) to 4.8% (CTAS 5). CTAS 3 patients represented over half of all visits and the highest absolute number of return admissions. A strong negative correlation was observed between CTAS level and URV admission rate (Pearson r = -0.89; p = 0.04). Linear regression confirmed a statistically significant inverse trend, with each one-point increase in CTAS corresponding to a 5.4% absolute reduction in admission rate (R² = 0.90, p = 0.014). Patients triaged as CTAS 1-2 had a relative risk of 1.90 (95% CI: 1.57 to 2.30) for admission on return compared to those triaged as CTAS 3-5. Conclusions The initial CTAS level is a strong predictor of admission following URVs. Stratified analysis revealed that CTAS 3 patients comprise a clinically important group, both in volume and admission risk. These findings support the use of triage-based reporting in ED quality improvement initiatives.

Emergency department (ED) triage prioritizes patients on the basis of the urgency of need for care. eTRIAGE is a Web-based triage decision support tool that is based on the Canadian Triage and Acuity Scale (CTAS), a five level triage system (CTAS 1 = resuscitation, CTAS 5 = nonurgent). To examine the validity of eTRIAGE on the basis of resource utilization and cost as measures of acuity. Scores on the CTAS, specialist consultations, computed-tomography use, ED length of stay, ED disposition, and estimated ED and hospital costs (if the patient was subsequently admitted to hospital) were collected for each patient over a six month period. These data were queried from a database that captures all regional ED visits. Correlations between CTAS score and each outcome were measured by using logistic regression models (categorical variables), univariate analysis of variance (continuous variables), and the Kruskal-Wallis analysis of variance (costs). A multivariate regression model that used cost as the outcome was used to identify interaction between the variables presented. Over the six month study, 29,524 patients were triaged by using eTRIAGE. When compared with CTAS level 3, the odds ratios for consultation, CT scan, and admission were significantly higher in CTAS 1 and 2 and were significantly lower in CTAS 4 and 5 (p < 0.001). When compared with CTAS levels 2-5 combined, the odds ratio for death in CTAS 1 was 664.18 (p < 0.001). The length of stay also demonstrated significant correlation with CTAS score (p < 0.001). Costs to the ED and hospital also correlated significantly with increasing acuity (median costs for CTAS levels in Canadian dollars: CTAS 1 = 2,690 dollars, CTAS 2 = 433 dollars, CTAS 3 = 288 dollars, CTAS 4 = 164 dollars, CTAS 5 = 139 dollars, and p < 0.001). Significant interactions between the data collected were found in a multivariate regression model, although CTAS score remained highly associated with costs. Acuity measured by eTRIAGE demonstrates excellent predictive validity for resource utilization and ED and hospital costs. Future research should focus on specific presenting complaints and targeted resources to more accurately assess eTRIAGE validity.

Background Emergency department (ED) triage prioritizes patients on the basis of the urgency of need for care. eTRIAGE is a Web-based triage decision support tool that is based on the Canadian Triage and Acuity Scale (CTAS), a five level triage system (CTAS 1 = resuscitation, CTAS 5 = nonurgent). Objectives To examine the validity of eTRIAGE on the basis of resource utilization and cost as measures of acuity. Methods Scores on the CTAS, specialist consultations, computed-tomography use, ED length of stay, ED disposition, and estimated ED and hospital costs (if the patient was subsequently admitted to hospital) were collected for each patient over a six month period. These data were queried from a database that captures all regional ED visits. Correlations between CTAS score and each outcome were measured by using logistic regression models (categorical variables), univariate analysis of variance (continuous variables), and the Kruskal-Wallis analysis of variance (costs). A multivariate regression model that used cost as the outcome was used to identify interaction between the variables presented. Results Over the six month study, 29,524 patients were triaged by using eTRIAGE. When compared with CTAS level 3, the odds ratios for consultation, CT scan, and admission were significantly higher in CTAS 1 and 2 and were significantly lower in CTAS 4 and 5 (p < 0.001). When compared with CTAS levels 2–5 combined, the odds ratio for death in CTAS 1 was 664.18 (p < 0.001). The length of stay also demonstrated significant correlation with CTAS score (p < 0.001). Costs to the ED and hospital also correlated significantly with increasing acuity (median costs for CTAS levels in Canadian dollars: CTAS 1 =$2,690, CTAS 2 =$433, CTAS 3 =$288, CTAS 4 =$164, CTAS 5 =$139, and p < 0.001). Significant interactions between the data collected were found in a multivariate regression model, although CTAS score remained highly associated with costs. Conclusions Acuity measured by eTRIAGE demonstrates excellent predictive validity for resource utilization and ED and hospital costs. Future research should focus on specific presenting complaints and targeted resources to more accurately assess eTRIAGE validity.

Background/Aim: Triage systems are crucial for determining patient care priorities and efficiently utilizing resources in emergency departments. The aim of this study is to compare the effectiveness of the three-stage triage system (TR) and the Canadian Triage and Acuity Scale (CTAS) system in terms of patient safety, resource management, and alignment with expert opinions in an adult emergency department. Methods: A prospective, cross-sectional, single-blind clinical study was conducted in an adult emergency department between October 1 and October 15, 2021. Patients aged 15 years and older with a Glasgow Coma Scale (GCS) score of 15 were included in the study. Trauma patients, patients transported by ambulance, and patients under 15 years of age were excluded from the study. CTAS was applied by a single emergency medicine resident on odd days of the month, while TR was applied on the even days. The specialist physician who provided the reference triage categories was unaware of the initial assessments. Primary outcomes included inter-rater agreement (weighted kappa coefficient), triage accuracy, and resource utilization patterns. Statistical analysis used the Kruskal-Wallis H test, Fisher's exact test, and a weighted kappa coefficient with a significance level set at P&lt;0.05. Results: A total of 620 patients were evaluated (TR: n=290, CTAS: n=330). CTAS demonstrated significantly higher agreement with expert opinion compared to TR (κ=0.375, P&lt;0.001) (κ=0.835, P&lt;0.001). In CTAS, the rate of inadequate triage was significantly lower (12%) compared to TR (28%). CTAS demonstrated a more balanced patient distribution across emergency levels and rational resource utilization, resulting in appropriate requests for radiological examinations at T3 level (32.35% compared to 78.95% in the yellow zone of TR, P&lt;0.001). Hospital admission rates were higher in CTAS (seven patients) compared to TR (one patient). Conclusion: The CTAS system demonstrated significantly higher compliance and lower triage error rates compared to the TR system, with expert consensus, thereby showing superior performance in terms of patient safety and resource management. The implementation of CTAS in emergency departments may improve the quality of patient care and optimize resource utilization.

Introduction: The Canadian Triage and Acuity Scale (CTAS) identifies the level of urgency when patients arrive to the Emergency department (ED). Sepsis is challenging to recognize and is associated with significant mortality (30 to 50%). The integration of the COP criteria allows for earlier detection and management of sepsis.The CTAS's validity and reliability are debated. The NEWS score has been suggested to allow a timely recognition of sepsis.Objectives:To describe patient orientation at ED triage with the NEWS vs. the CTAS and COP criteria and to identify the NEWS's ability to detect patients who will require admission to critical care. Methods: Design: A retrospective cohort study of ED 225 patients (January-November 2018) is was constituted. Participants: Patients were included if they were aged ≥18, consulting to the ED, presented one of the 32 diagnoses included in the CMI-10. Measurements: Retained variables are sex, age, CTAS score and level of care. The NEWS score was calculated from triage vital signs. Main outcome was Patient orientation after ED triage using CTAS vs the NEWS score. Descriptive statistics to determine patient orientation based on the NEWS and CTAS were performed. Fisher tests (α = 0.05) were used to assess a possible association between both triage scales and identify the NEWS's ability to detect patients who will require admission to critical care during. Sample size was calculated in order to detect a 15% difference between actual orientation and theoretical orientation based on the NEWS. Results: The retained cohort (45% men) were aged 66 ± 21 years. 67% were admitted, 14% of which to a critical care unit. Average length of hospital stay was 6.3 ± 7.8 days. Primary objective: patient orientation after triage using CTAS vs the NEWS was: 29% vs. 18% for high risk patients; 2% vs. 67% for low risk patients (p &amp;lt; 0.0001), respectively. Secondary objective: Among patients with stable NEWS score, 53% were admitted to hospital among patients with medium NEWS score, 9% of patients were admitted to the critical care (p = 0.0003) Conclusion: Patient orientation after ED triage using CTAS vs the NEWS is significantly different. The NEWS alone does not seem to be able to detect patients who will require admission to critical care. Future studies exploring an aggregate scoring system combining the NEWS and CTAS could be performed to determine if sepsis recognition and patient orientation can be improved

Background: Triage system is prioritizing patients according to their urgency to deal with overcrowding of non-urgent patients in the Emergency Department (ED). The aim of this study is to evaluate the admission of non-urgent patients in order to decrease the burden on the ED by triaging them away to the Primary Health Care (PHC). Design and Methods: This retrospective cohort study included all adult non-trauma ED visits in King Abdullah Medical City (KAMC), triaged as Canadian Triage and Acuity Scale (CTAS) IV and V, from May 9 to July 8, 2019. The data was extracted from KAMC database onto SPSS. Multivariate logistic regression was used to examine which factors could affect admission. Results: CTAS IV and CTAS V patients were 30.31% (1495/5066) of total ED visits. Admission was 6.02%; 5.8% for CTAS IV and 0.2% for CTAS V. All CTAS V admissions were elective. Nausea and vomiting (14.4%) were the most frequent chief complaints in the admitted group. The overall referral of non-urgent patients was 12.4% and bounce-back was 13.7%. Logistic regression showed that being tachypneic (OR: 6.68; 95%CI: 1.4-31.5), hypertensive (OR: 3.4; 95%CI: 2.2-5.4) or an oncology patient (OR: 2.85; 95%CI: 1.8-4.6) predicted hospital admission. Conclusion: All CTAS V cases can be safely triaged away to the PHC; CTAS IV can be either triaged away to PHC or to urgent care center, taking into consideration whether the patient is tachypneic, hypertensive or an oncology patient.

Introduction: In the Canadian province of Alberta, (pop. 4,227,879), the publicly-funded health care system uses the five level Canadian Triage and Acuity Scale (CTAS), to prioritize emergency department (ED) patients. Health system decision makers and policy makers currently use CTAS as an isolated metric to describe ED patient case-mix and to compare EDs. Methods: Using the National Ambulatory Care Reporting System dataset, we reviewed the distribution of patient CTAS scores and the proportion of inpatient admissions by CTAS level for the 16 highest volume Alberta hospital EDs during FY 2013/2014. Results: Collectively, the EDs received 1,027,976 patients, with 1%, 18%, 44%, 30% and 7% classified as CTAS 1-5, respectively. The proportions by CTAS level ranged from 0.2% to 2.8% in CTAS 1; 3.3% to 33.3% in CTAS 2; 29.1% to 54.1% in CTAS 3; 16.7% to 49.0% in CTAS 4; and 3.1% to 12.3% in CTAS 5. Admission proportions by CTAS level ranged from 43.9% to 75.2% in CTAS 1; 18.9% to 42.1% in CTAS 2; 5.4% to 24.7% in CTAS 3; 0.8% to 9.3% in CTAS 4; and 0.1% to 9.1% in CTAS 5. Conclusion: Inter-hospital differences in CTAS acuity distributions reflect triage variability and real differences in case-mix. Wide variation in admission proportions by CTAS level reflects differing admission thresholds between sites, but also suggest intra-level differences in patient severity, comorbidity and complexity. Triage levels cannot be used as an isolated metric to describe and compare ED case-mix. Further work is required to accurately characterize ED patient case-mix.

Wait times in Winnipeg emergency departments (EDs) are currently amongst the longest in Canada. With the goal of improving wait times and lower costs, the Winnipeg Regional Health Authority plans to consolidate services by closing one ED and one urgent care centre, while converting two EDs to urgent care centres. With the conversion of EDs in Winnipeg to urgent care centres, an analysis of new and cost-effective models of managing the less acute, but urgent medical conditions typically seen at urgent care centres, is needed.The objective of this study was to identify the Canadian Triage and Acuity Scale (CTAS) classification of illness severity that Physician Assistants (PAs) are currently treating in rural EDs in Manitoba. Patient charts were reviewed from the emergency departments of Beausejour District Hospital and Selkirk Regional Health Centre between January and May 20017. The majority of patients treated by PAs in these rural EDs were of CTAS levels 3 and 4. This study highlights that PAs are experienced in treating CTAS level 3 presentations and are utilized to help increase patient flow in these rural emergency departments. Furthermore, with the increased need to find cost-effective and innovative ways of reducing wait times in Winnipeg EDs and urgent care centers, it may be suggested that PAs could be beneficial in this process.

Comparison Between Canadian Triage and Acuity Scale and Taiwan Triage System in Emergency Departments

Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, ED funding and workload models. The Electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes the application of national triage guidelines (CTAS) across Ontario. The objective of this study was to evaluate the implementation of eCTAS in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1200 (738 pre-eCTAS, 462 post-implementation) individual patient CTAS assessments were audited over 33 (21 pre-eCTAS, 11 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients pre-eCTAS, compared to 429 (93.0%) patients triaged with eCTAS. Using the auditors CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.1% vs. 3.2%; 8.9, 95% CI: 5.7, 11.7) and under-triaged (12.9% vs. 3.9%; 9.0, 95% CI: 5.9, 12.0). Interrater agreement was higher with eCTAS (unweighted kappa 0.90 vs 0.63; quadratic-weighted kappa 0.79 vs. 0.94). Research assistants captured triage time for 4403 patients pre-eCTAS and 1849 post implementation of eCTAS. Median triage time was 304 seconds pre-eCTAS and 329 seconds with eCTAS ( 25 seconds, 95% CI: 18, 32 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.

IMPACT OF EMERGENCY DEPARTMENT TRIAGE ON TIMELY ECG ACQUISITION

Introduction: The Canadian Triage and Acuity Scale (CTAS) is the standard used in all Canadian (and many international) emergency departments (EDs) for establishing the priority by which patients should be assessed. In addition to its clinical utility, CTAS has become an important administrative metric used by governments to estimate patient care requirements, ED funding and workload models. Despite its importance, the process by which CTAS scores are derived is highly variable. Emphasis on ED wait times has also drawn attention to the length of time the triage process takes. The primary objective of this study was to determine the interrater agreement of CTAS in current clinical practice. The secondary objective was to determine the time it takes to triage in a variety of ED settings. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded the triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 738 consecutive patient CTAS assessments were audited over 21 seven-hour triage shifts. Exact modal agreement was achieved for 554 (75.0%) patients. Using the auditor’s CTAS score as the reference standard, on-duty triage nurses over-triaged 89 (12.1%) and under-triaged 95 (12.9%) patients. Interrater agreement was “good” with an unweighted kappa of 0.63 (95% CI: 0.58, 0.67) and quadratic-weighted kappa of 0.79 (95% CI: 0.67, 0.90). Research assistants captured triage time for 3808 patients over 69 shifts at 7 different EDs. Median (IQR) triage time was 5.2 (3.8, 7.3) minutes and ranged from 3.9 (3.1, 4.8) minutes to 7.5 (5.8, 10.8) minutes. Conclusion: Variability in the accuracy, and length of time taken to perform CTAS assessments suggest that a standardized approach to performing CTAS assessments would improve both clinical decision making, and administrative data accuracy.

BackgroundEmergency care continues to be a challenge, since patients’ arrival is unscheduled and could occur at the same time which may fill the Emergency Department with non-urgent patients. Triaging is an integral part of every busy ED. The Canadian Triage and Acuity Scale (CTAS) is considered an accurate tool to be used outside Canada. This study aims to identify the chosen triage level and compare the variation between registered nurses, pediatric and adult emergency residents by using CTAS cases.MethodThis study was conducted at King Abdulaziz Medical City,Saudi Arabia. A cross-sectional self-administered questionnaire was used, and which contains 15 case scenarios with different triage levels. All cases were adopted from a Canadian triage course after receiving permission. Each case provides the patient’s symptoms, clinical signs and mode of arrival to the ED. The participants were instructed to assign a triage level using the following scale. A non-random sampling technique was used for this study. The rates of agreement between residents were calculated using kappa statistics (weighted-kappa) (95%CI).ResultA total of 151 participants completed the study questionnaire which include 15 case scenarios. 73 were nurses and 78 were residents. The results showed 51.3, 56.6, and 59.9% mis-triaged the cases among the nurses, emergency residents, and pediatric residents respectively. Triage scores were compared using the Kruskal Wallis test and were statistically significant with a p value of 0.006. The mean ranks for nurses, emergency residents and pediatric residents were 86.41, 73.6 and 59.96, respectively. The Kruskal Wallis Post-Hoc test was performed to see which groups were statistically significant, and it was found that there was a significant difference between nurses and pediatrics residents (P value = 0.005). Moreover, there were no significant differences found between nurses and ER residents (P value> 0.05).ConclusionThe triaging system was found to be a very important tool to prioritize patients based on their complaints. The results showed that nurses had the greatest experience in implementing patients on the right triage level. On the other hand, ER and pediatric residents need to develop more knowledge about CTAS and become exposed more to the triaging system during their training.