Abstract
BackgroundPatients with neurological symptoms have been contributing to the increasing rates of emergency department (ED) utilization in recent years. Existing triage systems represent neurological symptoms rather crudely, neglecting subtler but relevant aspects like temporal evolution or associated symptoms. A designated neurological triage system could positively impact patient safety by identifying patients with urgent need for medical attention and prevent inadequate utilization of ED and hospital resources.MethodsWe compared basic demographic information, chief complaint/presenting symptom, door-to-doctor time and length of stay (LOS) as well as utilization of ED resources of patients presenting with neurological symptoms or complaints during a one-month period before as well as after the introduction of the Heidelberg Neurological Triage System (HEINTS) in our interdisciplinary ED. In a second step, we compared diagnostic and treatment processes for both time periods according to assigned acuity.ResultsDuring the two assessment periods, 299 and 300 patients were evaluated by a neurologist, respectively. While demographic features were similar for both groups, overall LOS (p < 0.001) was significantly shorter, while CT (p = 0.023), laboratory examinations (p = 0.006), ECG (p = 0.011) and consultations (p = 0.004) were performed significantly less often when assessing with HEINTS. When considering acuity, an epileptic seizure was less frequently evaluated as acute with HEINTS than in the pre-HEINTS phase (p = 0.002), while vertigo patients were significantly more often rated as acute with HEINTS (p < 0.001). In all cases rated as acute, door-to-doctor-time (DDT) decreased from 41.0 min to 17.7 min (p < 0.001), and treatment duration decreased from 304.3 min to 149.4 min (p < 0.001) after introduction of HEINTS triage.ConclusionA dedicated triage system for patients with neurological complaints reduces DDT, LOS and ED resource utilization, thereby improving ED diagnostic and treatment processes.
Highlights
IntroductionA further illustration of this “safety thinking” in the context of neurological symptoms is provided by study a by Robertson et al, who found that only one third of patients referred for neurological assessment to a rapid referral neurological acute clinic were retrospectively considered to have warranted an urgent evaluation [35]
Emergency department (ED) utilization in many countries has substantially increased in the last two decades [32]
Neurological symptoms appear to be inadequately represented in established triage systems like the Manchester Triage System (MTS) or the Emergency Severity Index (ESI): While there are no dedicated investigations into the performance of currently used systems in neurological patients, Lange et al found that over 50% of emergency department (ED) neurological patients were triaged into ESI category 2, which allows for a door-to-doctor time of up to 10 min [16]
Summary
A further illustration of this “safety thinking” in the context of neurological symptoms is provided by study a by Robertson et al, who found that only one third of patients referred for neurological assessment to a rapid referral neurological acute clinic were retrospectively considered to have warranted an urgent evaluation [35] It follows that gate-keeping practices need to be established in order to adequately and economically allocate limited ED resources. Treatment of patients presenting with neurological emergencies such as an acute ischemic stroke, cerebral hemorrhage, status epilepticus or meningoencephalitis is often time-sensitive and requires immediate recognition and swift management in the ED [4, 9, 30, 40] This two-faceted scenario is ideal for the application of a triage procedure since triage systems were developed to facilitate acuity assessment as well as to predict patient disposition and resource utilization [11, 22]. A designated neurological triage system could positively impact patient safety by identifying patients with urgent need for medical attention and prevent inadequate utilization of ED and hospital resources
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