5-level System Research Articles

103 Level 4 and Level 5 Emergency Department Fees in Florida Vary Widely

103 Level 4 and Level 5 Emergency Department Fees in Florida Vary Widely

Evaluation of the Maternal-Fetal Triage Index in a tertiary care labor and delivery unit

The Maternal-Fetal Triage Index is a 5-level system to facilitate the care of pregnant women seeking care in an obstetrical triage unit (priority 1 being the highest acuity and priority 5 being the lowest acuity). Although the American College of Obstetricians and Gynecologists recommends implementing labor and delivery triage tools, it remains unclear whether the Maternal-Fetal Triage Index facilitates the timely evaluation of high-acuity pregnant women. We sought to examine the duration of a labor and delivery triage evaluation before and after the implementation of the Maternal-Fetal Triage Index. We also sought to examine the duration of a labor and delivery triage evaluation according to priority levels by the Maternal-Fetal Triage Index. This was a retrospective quality improvement study of all women presenting to an urban, tertiary labor and delivery triage unit at 16 weeks' gestation or later from December 2017 to February 2018 (historical cohort) and December 2018 to February 2019 (study cohort). As part of a quality improvement initiative, the Maternal-Fetal Triage Index was implemented in the labor and delivery unit in May 2018. All registered nurses who worked in the labor and delivery unit completed a formal education course and assigned the priority levels at the time of triage presentation. The primary outcome was the duration of a labor and delivery triage evaluation, which was defined as the time interval from triage presentation to the completion of history and physical examination in the electronic medical record. Secondary outcomes included the rates of labor and delivery unit admissions. There were 1305 and 1374 women in the historical cohort and study cohort, respectively. The duration of labor and delivery triage evaluation was longer for the study cohort than for the historical cohort (64 minutes vs 61 minutes; P=.02). Of the 1374 women in the study cohort, there were 28 (2%), 290 (21%), 459 (33%), 462 (34%), and 135 (10%) women with priority levels 1, 2, 3, 4, and 5 assigned, respectively. Women with a higher priority according to the Maternal-Fetal Triage Index had a shorter labor and delivery triage evaluation (priority 1, 57 minutes; priority 2, 66 minutes; priority 3, 63 minutes; priority 4, 62 minutes; and priority 5, 83 minutes; P<.001). The rates of admission were higher in the priority 1 and 5 groups (priority 1, 89.3%; priority 2, 41.4%; priority 3, 57.3%; priority 4, 53.3%; and priority 5, 92.6%; P<.001). Compared with the historical cohort, the duration of labor and delivery triage evaluation was longer in the study cohort. However, in the study cohort, women classified as higher priority according to the Maternal-Fetal Triage Index had a shorter labor and delivery triage evaluation. Our study supports the American College of Obstetricians and Gynecologists' recommendation on the implementation and utilization of labor and delivery triage tools such as the Maternal-Fetal Triage Index.

Readiness of US General Surgery Residents for Independent Practice.

This study evaluates the current state of the General Surgery (GS) residency training model by investigating resident operative performance and autonomy. The American Board of Surgery has designated 132 procedures as being "Core" to the practice of GS. GS residents are expected to be able to safely and independently perform those procedures by the time they graduate. There is growing concern that not all residents achieve that standard. Lack of operative autonomy may play a role. Attendings in 14 General Surgery programs were trained to use a) the 5-level System for Improving and Measuring Procedural Learning (SIMPL) Performance scale to assess resident readiness for independent practice and b) the 4-level Zwisch scale to assess the level of guidance (ie, autonomy) they provided to residents during specific procedures. Ratings were collected immediately after cases that involved a categorical GS resident. Data were analyzed using descriptive statistics and supplemented with Bayesian ordinal model-based estimation. A total of 444 attending surgeons rated 536 categorical residents after 10,130 procedures. Performance: from the first to the last year of training, the proportion of Performance ratings for Core procedures (n = 6931) at "Practice Ready" or above increased from 12.3% to 77.1%. The predicted probability that a typical trainee would be rated as Competent after performing an average Core procedure on an average complexity patient during the last week of residency training is 90.5% (95% CI: 85.7%-94%). This falls to 84.6% for more complex patients and to less than 80% for more difficult Core procedures. Autonomy: for all procedures, the proportion of Zwisch ratings indicating meaningful autonomy ("Passive Help" or "Supervision Only") increased from 15.1% to 65.7% from the first to the last year of training. For the Core procedures performed by residents in their final 6 months of training (cholecystectomy, inguinal/femoral hernia repair, appendectomy, ventral hernia repair, and partial colectomy), the proportion of Zwisch ratings (n = 357) indicating near-independence ("Supervision Only") was 33.3%. US General Surgery residents are not universally ready to independently perform Core procedures by the time they complete residency training. Progressive resident autonomy is also limited. It is unknown if the amount of autonomy residents do achieve is sufficient to ensure readiness for the entire spectrum of independent practice.

Enhanced negative refractive index control in a 5-level system

In this paper we demonstrate that for a five-level atomic system in a dense gas interacting with two low-intensity fields by adjusting the ratio of the two magnetic amplitudes associated with the fields the effects of atomic coherence can be simply controlled. Furthermore, a negative index of refraction can be achieved over a wide wavelength range with minimal absorption.

General tracking control of arbitrary N-level quantum systems using piecewise time-independent potentials

Here we propose a tracking quantum control protocol for arbitrary N-level systems. The goal is to make the expected value of an observable $${\mathcal O}$$O to follow a predetermined trajectory S(t). For so, we drive the quantum state $$|\varPsi (t) \rangle $$|?(t)? evolution through an external potential V which depends on $$M_V$$MV tunable parameters (e.g., the amplitude and phase (thus $$M_V = 2$$MV=2) of a laser field in the dipolar condition). At instants $$t_n$$tn, these parameters can be rapidly switched to specific values and then kept constant during time intervals $$\Delta t$$Δt. The method determines which sets of parameters values can result in $$\langle \varPsi (t) | {\mathcal O} |\varPsi (t) \rangle = S(t)$$??(t)|O|?(t)?=S(t). It is numerically robust (no intrinsic divergences) and relatively fast since we need to solve only nonlinear algebraic (instead of a system of coupled nonlinear differential) equations to obtain the parameters at the successive $$\Delta t$$Δt's. For a given S(t), the required minimum $$M_V = M_{\min }$$MV=Mmin `degrees of freedom' of V attaining the control is a good figure of merit of the problem difficulty. For instance, the control cannot be unconditionally realizable if $$M_{\min } > 2$$Mmin>2 and V is due to a laser field (the usual context in real applications). As it is discussed and exemplified, in these cases a possible procedure is to relax the control in certain problematic (but short) time intervals. Finally, when existing the approach can systematically access distinct possible solutions, thereby allowing a relatively simple way to search for the best implementation conditions. Illustrations for 3-, 4-, and 5-level systems and some comparisons with calculations in the literature are presented.

Comparison study of two diagnostic and grading systems for conjunctivochalasis

Background Different diagnostic and grading systems of conjunctivochalasis have resulted in apparent disparity between the prevalence rates of recent population-based studies. This study aimed to investigate the disparity between 4-level system cited from Meller and Tseng in 1998 (abbreviated here as Meller's system) and 5-level system modified from Meller's system cited from Zhang and associates (abbreviated here as Zhang's system) regarding the diagnosis and the patients' preferences for the treatment of conjunctivochalasis in the general population. Methods A total of 546 senile residents living in the Guiyangyuan community of Shanghai, China, participated in the study. The diagnostic criteria for conjunctivochalasis were based on two diagnostic grading systems: Meller's system and Zhang's system, which was modified from Meller's system. The participants' preference regarding medical treatment for conjunctivochalasis was determined according to the response to a question. One year later, a follow-up interview determines whether the patient had undergone surgery for conjunctivochalasis. Results With Meller's system, 398 participants were confirmed as having conjunctivochalasis, and the prevalence rate was 72.89%. According to Zhang's system, only 213 participants were diagnosed as having conjunctivochalasis, and the prevalence rate was 39.01%. A total of 109 eyes underwent medical treatment or surgery for conjunctivochalasis in the following year, including eight eyes that were diagnosed as grade II and 101 eyes that were diagnosed as grade III according to Meller's system and five eyes that were diagnosed as grade I, 55 eyes that were diagnosed as grade II, 31 eyes that were diagnosed as grade III, and 18 eyes that were diagnosed as grade IV according to Zhang's system. Conclusion Diagnoses of conjunctivochalasis using Zhang's system are more consistent with patient requests and the medical treatment strategies used than diagnoses made using Meller's system.

Can Emergency Nurses' Triage Skills Be Improved by Online Learning? Results of an Experiment

Emergency nurses deal with increasing complexity of patients. In 2003 there were over 14 million ED visits in Canada. The Canadian Triage and Acuity Scale (CTAS) is a 5-level system used by ED triage nurses to classify patients. There is a need for standardized training for all triage systems. In an effort to improve access to CTAS training, a 6-week Web-based CTAS workshop was developed. We determined the impact of Web learning on the accuracy of the triage skills of registered nurses (RNs). An experimental method was used in which 132 RNs were randomized to an intervention group (n = 65) or control group (n = 67). All RNs received exactly the same content and learning activities. The experimental group differed from the control group in 3 ways: a mandatory tutorial, awarding of marks for online discussion, and completion of a workplace project. Data were collected using standard instruments, chart audit, and interviews. The Web course provided a standardized and effective educational experience that enhanced emergency nurses' triage accuracy. The mandatory online tutorial, online discussion, and workplace project increased the RNs' preparation for online learning, and these educational methods were successful in transferring triage learning to practice. Web learning can help professionals maintain competency and support professional practice. Further research is needed to provide evidence for best practices in E-learning for RNs. The accuracy of the RN's triage assessment impacts patient health, hospital accreditation, and funding.

Calculating kappas from adjusted data improved the comparability of the reliability of triage systems: a comparative study

Objectives It is difficult to compare the reliability of triage systems with the kappa statistic. In this article, a method for comparing triage systems was developed and applied to previously conducted triage reliability studies. Study Design and Setting From simulations with theoretical distributions, the minimum, normal, and maximum weighted kappa for 3- to 5-level triage systems were computed. To compare the reliability of triage systems in previously conducted triage reliability studies, the normal kappa was calculated. Furthermore, the reported quadratically weighted kappas were compared with the minimum, normal, and maximum weighted kappa to characterize the degree and direction of skewness of the data. Results The normal kappa was higher in 3-level triage systems (median: κ = 0.84) compared with 4-level (median: κ = 0.37) and 5-level (median: κ = 0.57) systems. In 3-level triage systems, the percentages observed agreement were unequally distributed, which resulted in small quadratically weighted kappas. In 4- and 5-level systems, the percentages observed agreement were more equally distributed compared with 3-level systems, which resulted in higher quadratically weighted kappa values. Conclusion When comparing triage systems with different numbers of categories, one should report both the normal and quadratically weighted kappa. Calculating normal kappas from previously conducted triage reliability studies revealed substantial theoretical differences in interrater reliability of triage systems than previously reported.

Singular Perturbations and Lindblad-Kossakowski Differential Equations

We consider an ensemble of quantum systems described by a density matrix, solution of a Lindblad-Kossakowski differential equation. We focus on the special case where the decoherence is only due to a highly unstable excited state and where the spontaneously emitted photons are measured by a photo-detector. We propose a systematic method to eliminate the fast and asymptotically stable dynamics associated with the excited state in order to obtain another differential equation for the slow part. We show that this slow differential equation is still of Lindblad-Kossakowski type, that the decoherence terms and the measured output depend explicitly on the amplitudes of quasi-resonant applied field, i.e., the control. Beside a rigorous proof of the slow/fast (adiabatic) reduction based on singular perturbation theory, we also provide a physical interpretation of the result in the context of coherence population trapping via dark states and decoherence-free subspaces. Numerical simulations illustrate the accuracy of the proposed approximation for a 5-level systems.

Seven Years of Clinical Experience With Teleconsultation in Craniomaxillofacial Surgery

In this work the experiences from 50 telemedically supported treatments in craniomaxillofacial surgery are summarized and different setups for their technical realization are described. Furthermore, for the first time the innovative UMTS (universal mobile telecommunication system) is applied for the transmission of arthroscopic videos of the temporomandibular joint and other craniomaxillofacial structures. The combination of computer-assisted navigation technology in augmented reality environments with telecommunication is used for execution of interactive stereotaxic teleconsultation. Furthermore, treatments without navigation are telemedically supported. This study is composed of 4 technical system configurations: 1) integrated services digital network (ISDN)-based videoconferencing without remote control of the navigation computer; 2) transmission control protocol/internet protocol (TCP/IP)-based interactive teleconsultation via bundled ISDN lines (including remote control of the navigation computer); 3) TCP/IP-based interactive teleconsultation via network; 4) combination of TCP/IP-connection and ISDN-based videoconferencing. The telemedically supported treatments are: orbitozygomatic osteotomies, positioning of the mandibular condyle in orthognathic surgery, insertion of implants, positioning of the maxilla in orthognathic surgery, distraction osteogenesis, arthroscopies of the temporomandibular joint, and operation simulations on stereolithographic models. The surgical interventions are evaluated on a 5-level system performance scale from the technical point of view. In a separate trial 20 videosequences of arthroscopies of the temporomandibular joint are transmitted via UMTS cellular phones and independently evaluated by 3 experts (ie, a total of 60 streamings) to investigate feasibility of this technology in the field of craniomaxillofacial surgery. In the years from 1996 to 2002 a total of 50 treatments were telemedically supported. All intraoperative applications were successfully finished; 48 of 60 UMTS transmissions were finished without any interruptions in constant quality, slight interruptions were observed in 8 tests, and a complete breakdown was observed during 4 streamings that required a restart of the transmission. Resolution was sufficient to diagnose even tiny anatomic structures inside the temporomandibular joint, but orientation was hardly recognizable. In many applications telecommunication technology can contribute to a quality improvement in cranio- and maxillofacial surgery because of the global availability of specialized knowledge. The required technical expenditure for teleconsultation crucially depends on the infrastructure that is already available at the clinic and the remote site. UMTS is a promising technology with the potential to be valuable in numerous craniomaxillofacial applications.

Preparing ED Nurses to Use the Canadian Triage and Acuity Scale With Web-based Learning

The Canadian Triage and Acuity Scale (CTAS), a 5-level system, recently has emerged as a more sensitive, accurate, and reliable tool for rapid patient assessment.1 CTAS training was originally developed as a 1-day workshop, offered periodically at various sites.

Pediatric triage: a 2-tier, 5-level system in the United States.

Emergency care continues to be a challenge for the pediatric population. Pediatric emergency department (ED) visits have escalated to over 12.5 million/y. To provide quality care, the provider must strive to meet ED efficiency, patient safety, and federal regulations. One of the most critical and challenging areas is pediatric triage. International healthcare systems in Canada and Australia have designed national triage systems to address the needs of patient acuity, improve patient safety, and enhance customer satisfaction. The United States continues to have various triage systems that include 3-level, 4-level, and 5-level systems in a variety of ED settings. This paper describes a pediatric triage system in the United States with a 2-tier process for high volume and 5 levels of acuity for time to treatment with over 30,000 ED visits per year.