Acuity Scale Research Articles

The impact of reduced pediatric emergency care hours on the patterns of emergency department utilization

Purpose: The declining recruitment rate of pediatric residents in Korea has led to a decrease in the number of emergency departments (EDs) offering a 24/7 pediatric emergency care (PEC). This study evaluated the impact of reduced PEC hours on the utilization patterns of a single ED.Methods: We reviewed medical records of pediatric patients who were defined as individuals aged 14 years or younger undergoing pediatricians’ practices in a tertiary hospital ED in Korea. Given the reduction of PEC hours from full-time to 08:00-24:00 on September 27, 2022, the patients were grouped as those who visited during March 27, 2022-September 26, 2022 (“control”), and those who visited during September 27, 2022-March 26, 2023 (“reduction”). The following variables were analyzed between the 2 periods: the number of patients, age, sex, visits via ambulances, severity by the Korean Triage and Acuity Scale with high acuity (a level 1-2 of the scale), disease-related visits, time of visit, ED length of stay (EDLOS), disposition, chief complaints, and diagnoses.Results: Among 3,577 pediatric patients, 1,315 visited the ED during the reduction period, down by 41.9% in numbers from the control period. From the control to reduction periods, we observed an increase in the median age (from 3.0 years [interquartile range, 1.0-7.0] to 4.0 years [1.0-8.0]; P = 0.005) and decreases in the median EDLOS (from 140.0 minutes [80.0-217.0] to 104.0 minutes [54.0-169.8]; P < 0.001) and proportion of hospitalization (from 22.1% to 12.6%; P < 0.001). No change was observed in the proportions of highacuity cases or chief complaints. We noted decreases in infection-related diagnoses during the reduction.Conclusion: Reducing PEC hours was associated with shorter EDLOS, fewer hospitalizations, and older age, with no difference in the severity. Even with reduced PEC hours, relevant resources should be redistributed to ensure the accessibility to PEC.

Multilevel analysis of factors affecting the interhospital transfer of high-acuity pediatric patients: a focus on severe pediatric emergency patients

Purpose: The authors aimed to identify the factors affecting interhospital transfer (“transfer”) of severe pediatric patients who visited to an emergency department (ED).Methods: Using the Korean National ED Information System, we analyzed high-acuity patients aged 18 years or younger who visited EDs of local or regional emergency centers nationwide. The high acuity was defined as a Korean Triage and Acuity Scale 1-2. To investigate the factors associated with transfer, a multilevel modeling was selected, examining independent variables at both individual- and hospital-levels with transfer as a dependent variable.Results: A model consisting of variables at individual- and hospital-levels showed the factors as follows: mode of arrival(self-transport: odds ratio, 0.48 [95% confidence interval, 0.38-0.61]; other ambulances: 0.41 [0.24-0.71]; compared with firehouse ambulance), visit at 18:00-07:59 (0.75 [0.64-0.88]), intentional injury (1.59 [1.03-2.47]; compared with non-injury), decreased level of consciousness (drowsy: 1.94 [1.33-2.84]; stupor: 4.08 [2.99-5.57]; coma: 1.81 [1.26-2.60]; compared with alert), severe illness diagnosis (1.49 [1.12-1.98]), the number of all beds in EDs (1.02 [1.01-1.04]), and acceptance for treatment (0.92 [0.87-0.98]; with increment of 1%).Conclusion: This study confirms that both individual-level and hospital-level factors affect the transfer risk of severe pediatric patients in EDs. The study suggests the needs for direct transportation to specialized pediatric treatment facilities, and concentrated support for the pediatric emergency medical centers and pediatric trauma centers.

From triage to treatment

Background: The COVID-19 pandemic has had a significant impact on healthcare systems worldwide, leading to changes in presentation types, service utilization, and admission rates to emergency departments (ED). This study examines changes in ED visit patterns and triage misclassifications during the pandemic in Alberta, Canada. Methods: We conducted a retrospective population-level time-series analysis of all patients who presented to 12 EDs in the Edmonton Alberta Zone between March 3, 2019, and March 3, 2022. Routinely collected electronic health record data were analyzed and with primary categories of reporting including Canadian Triage Acuity Scale (CTAS), age, Canadian Emergency Department Information System (CEDIS) presenting complaint, admission status, triage misclassifications, and time markers for patient care. Results: 1.24 million cases from 12 hospitals were included. When we compare the patterns of presentation to the pre-pandemic period, we found a relative increase of 12.5% in EMS volumes, a 43.2% relative reduction in the proportion of patients presenting to tertiary EDs, 17.2% relative reduction in the number of patients under the age of 18, and a global increase in acuity with the highest relative increase 19.7% coming from patients in the highest acuity level: CTAS 1. Complaint distributions during these periods demonstrated that mental health, substance use, and environmental complaints experienced 15.5%, 22.4%, and 26.7% relative increases in volume, respectively; pediatric specific complaints experienced a 56.5% relative reduction. By the end of the study period, patients spent an average of 59 minutes longer in the ED compared to the pre-pandemic period. The proportion of patients triaged using Epic increased from 7.8% of all patients triaged in the pre-pandemic period to over 66.1% during the pandemic, and there was a 22.9% and 24.2% relative reduction in high-risk triage misclassifications (22.9%) and pain related triage misclassifications (24.2%) by the end of the period compared to the before the pandemic. Conclusion: Our study adds to the pandemic-related emergency care knowledge base by describing ED visit trends, changes in presenting complaint categories and time markers for patient care over a big-data pre and post pandemic dataset. Nursing-specific ED quality indicators that have not been previously described over a three-year duration between March 3rd 2019 and March 3rd 2022. are also presented. Our study findings have significant implications for healthcare professionals and policymakers in understanding both the impact of the pandemic on ED care delivery as well as future pandemic and post-pandemic ED operations.

33 Use of CHU Ste. Justine online resources prior to visiting the Emergency Department for less-urgent, acute febrile illness

Abstract Background Over the past 20 years, visits to paediatric emergency departments (EDs) across Canada have steadily increased, with a higher proportion of presentations for lower acuity symptoms. Many paediatric institutions’ websites now provide information and recommendations for caregivers on common illnesses and reasons for seeing healthcare providers or going to the ED. Increasing the use of internet resources may improve health literacy and hopefully decrease ED use for lower acuity presentations like uncomplicated viral illness. Objectives The objective of this study was to assess whether caregivers presenting with children with lower acuity at triage were aware of and using the online resources provided by our paediatric institution to help with at-home management of febrile illnesses and to guide their decision to present to the ED. Design/Methods This was a cross-sectional study in a tertiary care university-affiliated paediatric ED in an urban setting. Participants were a convenience sample of caregivers of children 6 months to 17 years old with a fever 72 hours or less and triaged low acuity (Canadian Triage and Acuity Scale levels 3 to 5). Caregivers of children with underlying significant systemic illness were excluded. Consenting participants completed two questionnaires. The first questionnaire included demographic data, information on baseline internet utilisation, use of general online health information and our institutions’ website specifically, and whether use of those resources influenced their decision to present to the ED. After browsing dedicated web materials developed by our institution (“Before going to the emergency room” and “Fever”), questionnaire 2 asked for feedback on the website. Results From April to July 2023, 100 caregivers participated in the study (response rates questionnaires 1 and 2: 80% and 70%, respectively) (Table 1). Half (49%) of caregivers researched their child’s symptoms prior to coming to the ED (Table 2). Approximately one third (39%) of respondents were aware that our institution provided online information for caregivers about common symptoms and when to present to the ED. Half (51%) of caregivers who completed questionnaire 2 said they would not have come to the ED if they had read these resources prior (Table 3). Many (66%) respondents reported they would be “likely/very likely” to look up their child’s symptoms on the institutional website before going to the ED in the future. Conclusion Half of caregivers presenting to the ED for their child’s lower-acuity febrile illness conducted research on their child’s symptoms prior to visiting the ED and most were influenced in their decision to come to ED by what they found. Most caregivers were not aware that our institution had online resources available. Promotion of the institutional resources available to parents may empower parents to manage common symptoms at home and prevent ED visits for lower-acuity illness.

Korean Triage and Acuity Scale education using role-playing and its effects on triage competency: A quasi-experimental design.

Triage is the process of prioritizing patients in the emergency department (ED). This has a pivotal role in ensuring patient safety and that the ED operates smoothly; therefore, triage training education is an important aspect of triage nurses' preparedness in different emergency situations. This study employed a quasi-experimental research design using a non-equivalent control group pre-post-test design to verify the effect of the Korean Triage and Acuity Scale (KTAS) education using role-playing on the knowledge of triage, triage performance ability, and triage competency in nursing students. Participants were 78 fourth-year nursing students from Shinseong University in South Korea; 39 were assigned to the experimental group, and 39 to the control group. The intervention was conducted for three weeks, from January 31 to February 16, 2024. The experimental group received KTAS education through role-playing, whereas the control group received triage education through lectures. Triage knowledge (t = 2.94, p = .004) and triage performance ability (t = 3.11, p = .003) were significantly improved in the experimental group. However, there was no significant difference in triage competency between groups (t = 1.32, p = .192). The post-test score of triage record in the experimental group showed a significant improvement over time (t = 0.56, p < .001). This study demonstrated that KTAS education using role-playing was more effective in improving triage knowledge and performance ability than traditional lecture methods for nursing students. Triage education programs should be developed considering the effectiveness of various teaching methods.

FI-lab in the emergency department and adverse outcomes among acutely hospitalized older adults

BackgroundThe emergency department is treating a growing number of older patients with frailty, which has been linked to poorer outcomes. Urgency is generally emphasized in the emergency department based on indicators such as triage scores and early warning scores for decision-making. However, this approach may not be sufficient for frail older people. The Frailty Index-laboratory (FI-lab) has been used as a simple assessment tool for frailty, but it may also reflect disease severity and predict adverse outcomes in the emergency care setting. Therefore, we aimed to evaluate the association between FI-lab in the emergency room and adverse outcomes during hospitalization through comparison with assessments using triage and early warning scores. MethodsThis was a retrospective cohort study conducted in a tertiary hospital. The study included patients aged 65 years or older who were admitted to the general internal medicine ward after being initially evaluated in the emergency department. FI-lab was calculated using 24 laboratory parameters from blood tests. The National Early Warning Score (NEWS), the Japan Triage and Acuity Scale (JTAS), and the modified JTAS were also used as prognostic indicators, and their association with adverse outcomes was compared with that of FI-lab. ResultsIn total, 872 patients (mean age, 80.9 years; male, 52.6 %) were analyzed. Patients who died during hospitalization had a higher FI-lab than those who survived. In multiple regression analysis, FI-lab, NEWS, and the modified JTAS were significantly associated with in-hospital death and prolonged length of hospital stay. In contrast, none of these indices were associated with in-hospital falls. The FI-lab was independently associated with the likelihood of discharge to home. ConclusionsFI-lab evaluated in the emergency department reflected the severity of illness in acutely hospitalized older adults, similarly to NEWS and JTAS, and was a useful indicator for predicting adverse outcomes. These results may indicate the value of FI-lab for older adults in the acute care setting.

Implementing Triage-Bot: Supporting the Current Practice for Triage Nurses.

In Canada, emergency departments (ED) have 15.1 million unscheduled visits every year; this has been suggested to indicate that patients rely on ED to address the gaps experienced by 6.5 million Canadians who lack a primary care provider. When this large number of visits is coupled with a predicted shortage of 100,000 nurses in Canada by 2030, ED can be expected to face resource limitations, which highlights the importance of triage systems as a source of immediate support. Technology that incorporates innovative analytical methods, automation of routine, and efficient processing can be leveraged to enhance patient outcomes, streamline clinical processes, and improve the overall quality and efficiency of healthcare delivery. This paper aims to highlight how the Triage-Bot, a proposed AI system, can assist ED nurses when triaging patients. The Triage-Bot system is based on the Canadian Triage and Acuity Scale (CTAS), which currently serves as a standardized and highly effective tool for prioritizing patient care in emergency departments across the country. Pre-set and open-ended questions are asked using voice and video, allowing patients to describe their health concerns and conditions. Triage-Bot automatically measures the following vital signs: heart rate (HR), heart rate variability (HRV), oxygen saturation (SpO2), respiratory rate (RR), blood pressure (BP), blood glucose (BG), and stress. The system uses artificial intelligence models, particularly those with a deep learning approach that simultaneously analyzes both the user's facial expression and voice tone. Implementation: A systematic review addressed the implications of AI in nursing and concluded that it could contribute to patient care by providing personalized instructions and/or remotely monitoring patients. The Triage-Bot system can be implemented in healthcare facilities, such as emergency department waiting rooms. The information it collects can then be added to a patient's health records to support nurses in assessing the severity of each patient's condition. Limitations: If the system is accessed without a nurse's guidance, it is imperative that the user receives information regarding when to visit a healthcare provider or ED. Continuous improvements in Triage-Bot's accessibility for patients with varying abilities are required to ensure that the system remains user-friendly during times of illness. The voice and text interaction can also be influenced by a user's understanding of language, culture, and age-related factors.

A comparison of self-triage tools to nurse driven triage in the emergency department.

Canadian patients presenting to the emergency department (ED) typically undergo a triage process where they are assessed by a specially trained nurse and assigned a Canadian Triage and Acuity Scale (CTAS) score, indicating their level of acuity and urgency of assessment. We sought to assess the ability of patients to self-triage themselves through use of one of two of our proprietary self-triage tools, and how this would compare with the standard nurse-driven triage process. We enrolled a convenience sample of ambulatory ED patients aged 17 years or older who presented with chief complaints of chest pain, abdominal pain, breathing problems, or musculoskeletal pain. Participants completed one, or both, of an algorithm generated self-triage (AGST) survey, or visual acuity scale (VAS) based self-triage tool which subsequently generated a CTAS score. Our primary outcome was to assess the accuracy of these tools to the CTAS score generated through the nurse-driven triage process. A total of 223 patients were included in our analysis. Of these, 32 (14.3%) presented with chest pain, 25 (11.2%) with shortness of breath, 75 (33.6%) with abdominal pain, and 91 (40.8%) with musculoskeletal pain. Of the total number of patients, 142 (47.2%) completed the AGST tool, 159 (52.8%) completed the VAS tool and 78 (25.9%) completed both tools. When compared to the nurse-driven triage standard, both the AGST and VAS tools had poor levels of agreement for each of the four presenting complaints. Self-triage through use of an AGST or VAS tool is inaccurate compared to the established standard of nurse-driven triage. Although existing literature exists which suggests that self-triage tools developed for specific subsets of complaints may be feasible, our results would suggest that adopting the self-triage approach on a broader scale for all-comers to the ED does not appear to be a viable option to enhance the current triage process. Further study is required to show if self-triage can be used in the ED to optimize the triage process.

Predictive validity of resource-adjusted Korean Triage and Acuity Scale in pediatric gastrointestinal tract foreign body patients

Although paediatric patients with gastrointestinal (GI) foreign bodies require multiple resources, they often present with few or no discernible symptoms and are typically assigned a low acuity level during triage. We compared the predictive accuracy of the revised Korean Triage and Acuity Scale (rKTAS), which elevates acuity by one step in relation to anticipated resource utilization, with that of the conventional KTAS for clinical outcomes. This was a retrospective study of National Emergency Department Information System data. Data on patient and ED characteristics, resources used, and clinical outcomes were collected from January 2018 to December 2021 for patients with GI foreign bodies aged under 19. The primary outcome was rKTAS accuracy in predicting hospitalization, ICU admission, operating room (OR) use, and ED length of stay (EDLOS). The AUROC was used to evaluate the performance via of the KTAS and rKTAS. In total, 25,324 paediatric patients visited the ED for GI tract foreign bodies. The mean age was 3.8 years, and 51% (12,923) were between 1 and 4 year old. Although most (23,658; 93.4%) were discharged, 4.9% required hospitalization. Two or more resources were utilized in 2514 (9.9%) cases, and 3,514 individuals had their triage levels increased by one step. Compared with those of the KTAS, the AUROCs of the rKTAS for predicting overall hospitalization (p < 0.05), admission to general wards (p < 0.05), ICU admission (p = 0.01), and admission via the OR (p < 0.05)were higher than KTAS. Compared with that with the KTAS, the EDLOS with the rKTAS was longer at levels 1, 2, and 3. The adjusted rKTAS is a better predictor of clinical outcomes for paediatric patients with GI tract foreign bodies than the KTAS.

Identifying the obstacles facing emergency nurses regarding treating CTAS1 and CTAS2 in Saudi Arabia

BackgroundEmergency nurses play a pivotal role in delivering efficient emergency healthcare, yet they often encounter numerous challenges, especially while managing life-threatening cases, impacting both their well-being and patient satisfaction. This study seeks to identify the prevalent challenges faced by these nurses in Saudi hospitals when handling Canadian Triage and Acuity Scale (CTAS1 and CTAS2) cases, with the aim of mitigating or managing these issues in the future.MethodsThis study incorporated a mixed-method approach to identify obstacles in Emergency Department (ED) nursing treatment of CTAS1 and CTAS2 cases in two major Saudi Arabian hospitals. The research began with qualitative focus group interviews with expert ED nurses, followed by a quantitative survey to measure and explore relationships among the qualitative findings. Data analysis leveraged qualitative thematic analysis and principal component analysis, ensuring rigorous examination and validation of data to drive meaningful conclusions.FindingsFrom expert interviews, key challenges for emergency nurses were identified, including resource management, communication, training compliance, and psychological factors. A survey of 172 nurses further distilled these into five major issues: patient care management, handling critical cases, administration support, patient care delay, and stress from patients’ families.ConclusionThrough a mixed-method approach, this study pinpoints five pivotal challenges confronting emergency nurses in Saudi hospitals. These encompass difficulties in patient care management, the psychological toll of handling critical cases, inadequate administrative support, delays due to extended patient stays, and the stress induced by the presence of patients’ families, all of which significantly impede emergency department efficiency and compromise nurse well-being.

Factors Affecting Length of Stays in the Emergency Department of a Teaching Hospital: A Retrospective Study From Najran, Saudi Arabia.

Reducing the frequency of emergency department (ED) patient visits for treatment, particularly in urgent instances, is a global healthcare objective. Additionally, a more extended stay in the ED can harm a patient's prognosis during later hospitalization. This study aims to investigate the factors affecting the length of stay in the ED in a teaching hospital. A retrospective chart review study was done between January 1, 2021, and February 31, 2021, involving 122 adult patients who had delayed ED visits to King Khalid Hospital in Najran, Saudi Arabia. Data on the patient's characteristics, visit time, and the causes for the delay based on the Canadian Triage and Acuity Scale (CTAS) were gathered and analyzed. Factors associated with more than six hours of delay were investigated in a univariate analysis. The mean age was 52.3 ±13.5 years, and 42 (34.4%) were more than 65 years of age. More than half of the study population were female (n=66; 54.1%). Most delays occurred among CTAS 4 and 5 cases (47.5%), and 22 (18.0%) occurred during holidays. The mean delay time was 6.1 ±1.8 hours. The leading delay causes were multiple consultations with further investigations (37.7%) and conflict between the teams (36.1%). In univariate analysis, ED visiting at holiday time (OR: 0.14; 95% CI: 0.04-0.40, p <0.001) and CTAS 4 and 5 (OR: 2.22; 95% CI: 0.95-5.30, p = 0.003) significantly had more delay. Factors associated with delay in univariate analysis were multiple consultations with further investigations (OR: 2.82; 95% CI: 1.32-6.26, p = 0.013), various assessments in different ED areas with a late arrival of the specialist (OR: 0.43; 95% CI: 0.20-0.91, p = 0.042), and conflict between the teams (OR: 2.50; 95% CI: 1.17-5.54, p = 0.031). In this study, multiple assessments in different ED areas and conflict between the teams were the main factors that caused delays in ED. Implementing a timeframe monitoring system for consultations while emphasizing accelerated decision-making and disposition for patients and understanding teamwork collaboration may reduce patients' length of stay in the ED. Implementing these strategies and evaluating their impact on the length of stay in the ED requires further investigation.

A Nationwide Study on Emergency Department Utilization among Pediatric Patients in Korea: A Special Focus on Pediatric Emergency Medical Centers

Objective: Despite Korea’s low birth rate, pediatric emergency medical centers (PEMCs) are grappling with overcrowding. This study evaluates the use of PEMCs in Korea amid a declining birth rate and increased overcrowding.Methods: Data from 176 emergency medical centers (EMCs, 2018–2021) was analyzed using the National Emergency Department Information System, focusing on demographics, Korean Triage and Acuity Scale (KTAS) scores, and pediatric patient outcomes. The most common complaints and diagnoses were identified by the EMC level. This study also examined the characteristics of patients visiting PEMCs.Results: There was a 48% drop in pediatric visits to EMCs during the coronavirus disease 2019 (COVID-19) pandemic. The majority of patients were boys aged 1–4, primarily visiting in the evenings and weekends. The breakdown of cases included 66% disease-related and 34% injury-related. Notably, 8.5% of these visits were via ambulance, 36% were high-acuity according to KTAS, 88% resulted in discharge, and 11% in hospitalization. The median stay was 85 minutes, with 83% utilizing local emergency services. Fever, abdominal pain, and vomiting were the most common complaints, comprising 40% of all visits.Conclusion: Despite a decrease in birth rates, PEMC usage in Korea saw an initial rise followed by a significant decrease during the COVID-19 pandemic. Children aged 1–4 were the most frequent users. The majority of cases were medical rather than trauma-related, and resulted in patient discharge. Strategic redirection of non-urgent cases may help alleviate overcrowding in emergency departments.

Visualization of Keratopathy Associated With the Antibody-Drug Conjugate Belantamab Mafodotin Using Infrared Imaging in Patients With Multiple Myeloma.

The treatment of patients with relapsed/refractory multiple myeloma (RRMM) with the antibody-drug conjugate belantamab mafodotin is affected by ocular adverse effects, most frequently keratopathy with corneal microcyst-like epithelial changes (MECs). To assess ocular side effects, the "Keratopathy and Visual Acuity (KVA) scale," based on the extent of keratopathy subjectively graded on slit-lamp examination and the change in best corrected visual acuity from baseline, was created. Advanced corneal imaging techniques have been explored to further characterize MECs and identify objective imaging biomarkers. We examined whether infrared reflectance imaging of the anterior segment (AS-IR) could contribute to the assessment, monitoring, and documentation of corneal toxicity in patients treated with belantamab mafodotin. In addition to the KVA examination, AS-IR imaging was performed. AS-IR images were evaluated for presence of visible hyporeflective lesions and their spatial and temporal distribution between visits and compared with keratopathy identified on slit-lamp examination. To standardize the assessment, a scoring system for lesions on AS-IR was implemented for additional analysis. Nine patients undergoing treatment with belantamab mafodotin for up to 9 months were examined. All patients exhibited hyporeflective lesions on AS-IR imaging, indicative of corneal toxicity corresponding to MECs observed on slit-lamp examination. AS-IR lesions showed early occurrence, variable quantity and size, and distinct distribution patterns, correlating with clinical findings during treatment. As shown for belantamab mafodotin, AS-IR imaging represents a fast, noninvasive, supplemental method for documentation, monitoring, and assessment of corneal adverse effects during treatment with antibody-drug conjugates, which may enable more standardized analyses.

Patient stratification based on the risk of severe illness in emergency departments through collaborative machine learning models

ObjectivesEmergency department (ED) overcrowding presents a global challenge that inhibits prompt care for critically ill patients. Traditional 5-level triage system that heavily rely on the judgment of the triage staff could fail to detect subtle symptoms in critical patients, thus leading to delayed treatment. Unlike previous rivalry-focused approaches, our study aimed to establish a collaborative machine learning (ML) model that renders risk scores for severe illness, which may assist the triage staff to provide a better patient stratification for timely critical cares. MethodsThis retrospective study was conducted at a tertiary teaching hospital. Data were collected from January 2015 to October 2022. Demographic and clinical information were collected at triage. The study focused on severe illness as the outcome. We developed artificial neural network (ANN) models, with or without utilizing the Taiwan Triage and Acuity Scale (TTAS) score as one of the predictors. The model using the TTAS score is termed a machine-human collaborative model (ANN-MH), while the model without it is referred to as a machine-only model (ANN-MO). The predictive power of these models was assessed using the area under the receiver-operating-characteristic (AUROC) and the precision-recall curves (AUPRC); their sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and F1 score were compared. ResultsThe study analyzed 668,602 ED visits from 2015 to 2022. Among them, 278,724 visits from 2015 to 2018 were used for model training and validation, while 320,201 visits from 2019 to 2022 were for testing model performance. Approximately 2.6% of visits were by severely ill patients, whose TTAS scores ranged from 1 to 5. The ANN-MH model achieved a testing AUROC of 0.918 and AUPRC of 0.369, while for the ANN-MO model the AUROC and AUPRC were 0.909 and 0.339, respectively. Based on these metrics, the ANN-MH model outperformed the ANN-MO model, and both surpassed human triage classification. Subgroup analyses further highlighted the models' capability to identify higher-risk patients within the same triage level. ConclusionsThe traditional 5-level triage system often falls short, leading to under-triage of critical patients. Our models include a score-based differentiation within a triage level to offer advanced risk stratification, thereby promoting patient safety.

Validation of the Korean Version of the Clinical Frailty Scale-Adjusted Korean Triage and Acuity Scale for Older Patients in the Emergency Department.

Background and Objectives: The Clinical Frailty Scale (CFS), used to screen for prehospital frailty in patients aged >65 years, is simple, time-efficient, and has been validated in emergency departments (EDs). In this study, we analyzed whether the Korean Triage and Acuity Scale (KTAS) classification by level in older patients determined to have frailty based on the Korean version of the CFS increases the triage performance of the current KTAS. Materials and Methods: The primary outcome was 30-day in-hospital mortality, and secondary outcomes were hospital and intensive care unit (ICU) admissions. This study retrospectively analyzed prospectively collected data from three ED centers. Patients with a CFS score ranging from five (mildly frail) to nine (terminally ill) were categorized into the frailty group. We upgraded the KTAS classification of the frailty group by one level of urgency and defined this as the CFS-KTAS. Results: The cutoff values for predicting admission were three and two for the KTAS and CFS-KTAS, respectively. A significant difference was observed in the area under the receiver operating characteristic (AUROC) curve between the KTAS and CFS-KTAS. To predict ICU admission, the cutoff score was two for both scales. A significant difference was observed in the AUROC curve between the KTAS and CFS-KTAS. For predicting in-hospital mortality, the cutoff score was two for both scales. A significant difference was observed in the AUROC curve between the KTAS and CFS-KTAS. Conclusions: This study showed that the CFS-adjusted KTAS has a more useful prognostic value than the KTAS alone for predicting hospital outcomes in older patients.

Emergency department utilization by persons with rheumatoid arthritis: a population-based cohort study

Some emergency department (ED) visits by persons with rheumatoid arthritis (RA) may be avoidable. This study aims to describe ED use by persons with RA in Alberta, Canada over a 10-year period. Using linked population-based administrative datasets, the annual frequency of ED visits, timing of visits, acuity at presentation assessed (Canadian Triage Acuity Scale (CTAS)), return visits within 72 h, and final disposition were assessed. Most responsible diagnoses assessed by the ED provider were categorized. Between 2008 and 2017, a total of 48,633 persons with RA had 416,964 unique ED visits. There was a 41% relative increase in visits over the study period and within a fiscal year 37% of persons with RA on average attended an ED. Half of the visits were assessed as CTAS 4 ‘Less Urgent’ (31%) and CTAS 5 ‘Non-Urgent’ (19%). No specific diagnosis could be assigned in 36% of visits and RA was listed as the most responsible diagnosis in 2.5% of all visits. Hospital admissions, occurring on average for 14% of ED visits, increased by 15% over the 10 years, and were rare for CTAS 4 (6.4%) and CTAS 5 (1.4%) presentations. Male patients (difference to female 1.2%, 95%CI 0.6, 1.7) and urban patients (difference to rural 8.4%, 95%CI 7.7, 9.2) were more frequently admitted to hospital. Persons with RA have increased ED utilization over time, with a significant volume of less urgent and non-urgent visits. Opportunities for appropriate ambulatory care provision to reduce acute care use should be identified.

Predictability of the emergency department triage system during the COVID-19 pandemic.

Emergency department (ED) triage systems are used to classify the severity and urgency of emergency patients, and Korean medical institutions use the Korean Triage and Acuity Scale (KTAS). During the COVID-19 pandemic, appropriate treatment for emergency patients was delayed due to various circumstances, such as overcrowding of EDs, lack of medical workforce resources, and increased workload on medical staff. The purpose of this study was to evaluate the accuracy of the KTAS in predicting the urgency of emergency patients during the COVID-19 pandemic. This study retrospectively reviewed patients who were treated in the ED during the pandemic period from January 2020 to June 2021. Patients were divided into COVID-19-screening negative (SN) and COVID-19-screening positive (SP) groups. We compared the predictability of the KTAS for urgent patients between the two groups. From a total of 107,480 patients, 62,776 patients (58.4%) were included in the SN group and 44,704 (41.6%) were included in the SP group. The odds ratios for severity variables at each KTAS level revealed a more evident discriminatory power of the KTAS for severity variables in the SN group (P<0.001). The predictability of the KTAS for severity variables was higher in the SN group than in the SP group (area under the curve, P<0.001). During the pandemic, the KTAS had low accuracy in predicting patients in critical condition in the ED. Therefore, in future pandemic periods, supplementation of the current ED triage system should be considered in order to accurately classify the severity of patients.

Clinical characteristics of SARS-CoV-2 Omicron BA.2 infection and its impact on pediatric emergency care in northern Taiwan

BackgroundThe SARS-CoV-2 Omicron BA.2 outbreak started in Taiwan in April 2022. The pandemic posed a challenge to pediatric emergency departments (PEDs) because of increased PED visits and diverse clinical presentations. MethodsWe analyzed the clinical characteristics and impact of the Omicron BA.2 pandemic in patients who visited our PED from April 2022 to July 2022. The data from the Alpha variant pandemic during the same period in 2021 were compared with these findings. ResultsOverall, 10,878 children were enrolled, and 7047 (64.8%) children were positive for SARS-CoV-2 infection. They had a mean ± SD age of 5.3 ± 4.1 years. The rates of patients with Pediatric Taiwan Triage and Acuity Scale (Ped-TTAS) level 1 (most urgent) (12.3%) and level 2 (27.6%) increased. More children were triaged as most urgent during the Omicron BA.2 pandemic than during the Alpha variant pandemic (p < 0.001). Patients with SARS-CoV-2 infection were likely to present with high fever, croup, dyspnea, febrile seizures, headache, dizziness, and myalgia (all p < 0.001). Four hundred and eleven (5.8%) patients were admitted; 25 (0.4%) patients needed intensive care, including 11 (44.0%) with encephalopathy or encephalitis. Three (0.04%) patients died due to fulminant encephalitis, encephalitis with septic shock, and respiratory failure. ConclusionsThe number of PED visits and the Ped-TTAS level of disease severity significantly increased during the SARS-CoV-2 Omicron BA.2 outbreak. The most common symptom was fever, and high fever was more common in patients with SARS-CoV-2 Omicron BA.2 infection. The rates of patients with croup and febrile seizures also increased.

Quality improvement initiative: improving obstetric triaging practices in a rural maternal hospital in central India

Triaging of obstetric patients by emergency care providers is paramount. It helps provide appropriate and timely management to prevent further injury and complications. Standardised trauma acuity scales have limited applicability...

Triage—clinical reasoning on emergency nursing competency: a multiple linear mediation effect

BackgroundTriage is the first step in providing prompt and appropriate emergency nursing and addressing diagnostic issues. Rapid clinical reasoning skills of emergency nurses are essential for prompt decision-making and emergency care. Nurses experience limitations in emergency nursing that begin with triage. This cross-sectional study explored the mediating effect of perceived triage competency and clinical reasoning skills on the association between Korean Triage and Acuity Scale (KTAS) proficiency and emergency nursing competency.MethodsA web-based survey was conducted with 157 emergency nurses working in 20 hospitals in South Korea between mid-May and mid-July 2022. Data were collected utilizing self-administered questionnaires to measure KTAS proficiency (48 tasks), perceived triage competency (30 items), clinical reasoning skills (26 items), and emergency nursing competency (78 items). Data were analyzed using the PROCESS macro (Model 6).ResultsPerceived triage competency indirectly mediate the relationship between KTAS proficiency and emergency nursing competency. Perceived triage competency and clinical reasoning skills were significant predictors of emergency nursing competency with a multiple linear mediating effect. The model was found have a good fit (F = 8.990, P <.001) with, a statistical power of 15.0% (R² = 0.150).ConclusionsThis study indicates that improving emergency nursing competency requires enhancing triage proficiency as well as perceived triage competency, which should be followed by developing clinical reasoning skills, starting with triage of emergency nurses.