Canadian Emergency Department Triage Research Articles

Evaluation of the Risk Factors of Nosocomial Pneumonia and the Prevalence of Antibiotic Resistance in Trauma Patients in Need of Immediate Intervention

Background: Pneumonia is the most common nosocomial infection reported worldwide in intensive care units. This study aimed to evaluate the risk factors of nosocomial pneumonia and the frequency of antibiotic resistance in trauma patients who need immediate intervention. Patients and Methods: This prospective cohort study was conducted in Shahid Rajaei Trauma Hospital in Shiraz between 2020 and 2021. All the trauma patients who needed immediate intervention (levels 1 and 2 based on the Canadian Emergency Department Triage and Acuity Scale) and had no symptoms of infection were included. Patients who were discharged or died before 48 hours were excluded. Results: The results demonstrated that major trauma (Injury Severity Score [ISS] ≥16), intubation, and use of invasive mechanical ventilation increase nosocomial pneumonia and death rate. The most common causes of nosocomial infections were Acinetobacter baumannii (23%) and coagulase-negative staphylococcus (18.5%). The highest levels of antibiotic resistance were related to cefoxitin, erythromycin, ciprofloxacin, and trimethoprim-sulfamethoxazole. Conclusions: Major trauma, intubation, and invasive mechanical ventilation were the effective factors in the development of nosocomial pneumonia. Continuous monitoring for mentioned risk factors and strict surveillance of antibiotic prescription can decrease the prevalence of nosocomial infections and subsequent deaths.

A Machine Learning Approach for Monitoring and Classifying Healthcare Data-A Case of Emergency Department of KSA Hospitals.

The Emergency Departments (EDs), in hospitals located in a few important areas in Saudi Arabia, experience a heavy inflow of patients due to viral illnesses, pandemics, and even on a few special occasions events such as Hajj or Umrah, when pilgrims travel from one region to another with severe disease conditions. Apart from the EDs, it is critical to monitor the movements of patients from EDs to other wards inside the hospital or in the region. This is to track the spread of viral illnesses that require more attention. In this scenario, Machine Learning (ML) algorithms can be used to classify the data into many classes and track the target audience. The current research article presents a Machine Learning-based Medical Data Monitoring and Classification Model for the EDs of the KSA hospitals and is named MLMDMC-ED technique. The most important aim of the proposed MLMDMC-ED technique is to monitor and track the patient's visits to the EDs, the treatment given to them based on the Canadian Emergency Department Triage and Acuity Scale (CTAS), and their Length Of Stay (LOS) in the hospital, based on their treatment requirements. A patient's clinical history is crucial in terms of making decisions during health emergencies or pandemics. So, the data should be processed so that it can be classified and visualized in different formats using the ML technique. The current research work aims at extracting the textual features from the patients' data using the metaheuristic Non-Defeatable Genetic Algorithm II (NSGA II). The data, collected from the hospitals, are classified using the Graph Convolutional Network (GCN) model. Grey Wolf Optimizer (GWO) is exploited for fine-tuning the parameters to optimize the performance of the GCN model. The proposed MLMDMC-ED technique was experimentally validated on the healthcare data and the outcomes indicated the improvements of the MLMDMC-ED technique over other models with a maximum accuracy of 91.87%.

Bicycle injuries presenting to the emergency department during COVID-19 lockdown.

AimSince the start of the COVID‐19 pandemic, there have been many changes in the presenting complaints in paediatric emergency departments (EDs). We sought to characterise the impact of the COVID‐19 pandemic on bicycle‐related injuries in children presenting to a tertiary care paediatric ED.MethodsWe conducted a descriptive, cross‐sectional study of ED visits to a large urban tertiary children's hospital, comparing March to October 2020 (the study period) to the same date range 2 years prior (i.e. March to October 2018–2019). We included children 0–17.99 years presenting for a bicycle‐related injury. We compared absolute visit counts of bike injuries per month, demographics, triage acuity, injury type and disposition.ResultsA total of 1215 bike‐related visits were analysed. There were 234 presentations in 2018 (March to October), 305 in 2019, and 676 in 2020. Overall, the mean age was 9.5 years (standard deviation 5.5–13.5), there were 67% males, median Canadian Emergency Department Triage and Acuity Scale score was 3 (interquartile range 3–4) and the most common injuries were fractures (n = 471, 38.8%). There were significantly more bike injuries presenting to the ED per month in the COVID group, 33.7(17.9) versus 84.5(61.4) (two‐tailed P value = 0.041). There was no statistical difference in ‘severe injuries’ pre‐ versus post‐COVID (odds ratio 0.815 (95% confidence interval 0.611–1.088), P = 0.165).ConclusionThere was a significant increase in bicycle‐related injuries presenting to our ED during the pandemic, compared to previous years. Evaluating these trends will allow for the exploration of harm reduction strategies for preventing future bicycle‐related injuries.

Causes and Characteristics of Children Unintentional Injuries in Emergency Department and Its Implications for Prevention

Background: Child unintentional injuries have become a hot topic worldwide, and substantial regional disparities existed in causes and characteristics. To date, limited data are available to investigate the causes and characteristics of child unintentional injuries from hospitals for children in China.Methods: A cross-sectional study was conducted between January 2017 and December 2018 in Shanghai, China. Patients aged <18 years with an unintentional injury presented to the emergency department were enrolled. Demographic information, Pediatric Risk for Mortality III score, and outcome variables were retrieved from electronic health records (EHRs). Frequencies and proportions of categorical variables and means and SDs of continuous variables are presented. Chi-square test and Student's t-test were used for the comparison between groups, as appropriate. Logistic regression analysis was used to estimate potential risk factors for admission to the hospital.Results: A total of 29,597 cases with unintentional injuries were identified between January 2017 and December 2018, with boys vs. girls ratio of 1.75. Preschool children account for approximately two-thirds of unintentional injuries in the emergency department. A distinctive pattern of mechanisms of unintentional injuries between gender was documented, and sports injury was significantly higher in boys than in girls (10.2 vs. 7.8%). Compared with Canadian Emergency Department Triage and Acuity Scale (CTAS) Grade 3 patients, Grade 2 [odds ratio (OR) = 2.99, 95% CI = 1.93–4.63, P < 0.001] and Grade 1 (OR = 74.85, 95% CI = 12.93–433.14, P < 0.001) patients had higher risk of inhospital admission. For causes of injuries, compared with falling, foreign body and poison had a lower risk of inhospital admission, while transport injury (OR = 1.31, 95% CI = 1.07–1.59, P = 0.008) and high fall injury (OR = 2.58. 95% CI =1.48–4.49, P < 0.001) had a significantly higher risk of admission.Conclusions: There was a significant relationship between age-groups and unintentional injuries between gender, with decreased injuries among girls growing up older. Preventive measures should be taken to reduce transport injury and high fall injury, which had a significantly higher risk of admission.

Assessment of Daily Burden and Factors for Overcrowded Emergency Department at Tertiary Care Hospital of Karachi

Background: When in emergency room there is no enough area left to serve or to admit the subsequent sick patients who may require urgent attention and observation the setting is called as the overcrowded emergency room. Due to overcrowded emergency department the quality of services provided by the staff and doctors is compromised ultimately patients with severe diseases are ignored and this may be one of the causes for causalities.&#x0D; Objective: To assess the daily burden and factors responsible for overcrowding at emergency department of tertiary care hospital of Karachi.&#x0D; Methodology: It was a cross sectional study conducted at tertiary care hospital of Karachi from October 2020 to January 2021. Data of patients coming to adult emergency department of either gender were collected. Patients age &lt;14 were excluded as these were referred to pediatric emergency department. Data collection was done according to Canadian emergency department triage and acuity scale (CTAS).&#x0D; Results: Total number (N) of patients who visited emergency department in study duration was 13434. The mean number of patients who visited ED was 141±13during our study duration. There was no any significant difference in presenting complaint. Delay in investigations was found to be a reason of prolong stay and overcrowding in ED in our setting.&#x0D; Conclusion: Overcrowding of patients in our ED of our setting was a common problem. The number of staff, doctors and beds were not matching the number of patient flow in the department. The main reason of prolong stay in ED was delay in investigations.

Over-triage occurs when considering the patient's pain in Korean Triage and Acuity Scale (KTAS).

BackgroundThe Korean Triage and Acuity Scale (KTAS) was developed based on the Canadian Emergency Department Triage and Acuity Scale. In patients with pain, to determine the KTAS level, the pain scale is considered; however, since the degree of pain is subjective, this may affect the accuracy of KTAS. The purpose of this study was to evaluate the accuracy of KTAS in predicting patient's severity with the degree of pain used as a modifier.MethodA retrospective observational cohort study was conducted in an urban tertiary hospital emergency department (ED). We investigated patients over 16 years old from January to June 2016. The patients were divided into the pain and non-pain groups according to whether the degree of pain was used as a modifier or not. We compared the predictive power of KTAS on the urgency of patients between the two groups. Acute area registration in the ED, emergency procedure, emergency operation, hospitalization, intensive care unit admission, and 7-day mortality were used as markers to determine urgent patients.ResultsOverall, 24,253 patients were included in the study, with 9,175 (37.8%) in the pain group. The proportions of patients with KTAS 1–3 were 61.4% in the pain and 75.6% in the non-pain groups. Among patients with KTAS 2–3, the proportion of urgent patients was higher in the non-pain group than the pain group (p<0.001). The odds ratios for urgent patients at each KTAS level revealed a more evident discriminatory power of KTAS for urgent patients in the non-pain group. The predictability of KTAS for urgent patients was higher in the non-pain group than the pain group (area under the curve; 0.736 vs. 0.765, p-value <0.001).ConclusionsConsidering the degree of pain with KTAS led to overestimation of patient severity and had a negative impact on the predictability of KTAS for urgent patients.

Predictors of Admission in Adult Unscheduled Return Visits to the Emergency Department.

IntroductionThe 72-hour unscheduled return visit (URV) of an emergency department (ED) patient is often used as a key performance indicator in emergency medicine. We sought to determine if URVs with admission to hospital (URVA) represent a distinct subgroup compared to unscheduled return visits with no admission (URVNA).MethodsWe performed a retrospective cohort study of all 72-hour URVs in adults across 10 EDs in the Edmonton Zone (EZ) over a one-year period (January 1, 2015 – December 31, 2015) using ED information-system data. URVA and URVNA populations were compared, and a multivariable analysis identified predictors of URVA.ResultsAnalysis of 40,870 total URV records, including 3,363 URVAs, revealed predictors of URVA on the index visit including older age (>65 yrs, odds ratio [OR] 3.6), higher disease acuity (Canadian Emergency Department Triage and Acuity Scale [CTAS] 2, OR 2.6), gastrointestinal presenting complaint (OR 2.2), presenting to a referral hospital (OR 1.4), fewer annual ED visits (<4 visits, OR 2.0), and more hours spent in the ED (>12 hours, OR 2.0). A decrease in CTAS score (increase in disease acuity) upon return visit also increased the risk of admission (−1 CTAS level, OR 2.6). ED crowding at the index visit, as indicated by occupancy level, was not a predictor.ConclusionWe demonstrate that URVA patients comprise a distinct subgroup of 72-hour URV patients. Risk factors for URVA are present at the index visit suggesting that patients at high risk for URVA may be identifiable prior to admission.

Sex Differences in Cardiac Troponin Testing in Patients Presenting to the Emergency Department with Chest Pain.

Elevated cardiac troponin (cTn), with signs/symptoms of ischemia, is a key element in a diagnosis of myocardial infarction (MI). Underdiagnosis of MI in women has been attributed to atypical symptoms, inconsistent ECG findings, and less diagnostic testing. We sought to determine if there are sex differences in cTn testing following presentation to the emergency department (ED) with a chief complaint of ischemic chest pain (CP) and if presentation affects diagnostic assessment. All adults presenting to six hospital EDs in the Vancouver, Canada with a chief complaint of ischemic CP from 2009 to 2013 were included. The highest cTn level within 24 hours of ED presentation was used. CP was classified into cardiac- or respiratory dominant based on standard Canadian Emergency Department Triage and Acuity Scale coding. Chi-square testing was used to test for sex differences in CP categories and cTn testing within 24 hours. Logistic regression models were used to examine the association between sex, cTn testing, and CP categories. Of 27,063 patients with ischemic CP, cardiac presentation was more common in men than women, irrespective of age. Among cardiac CP, 24.7% of men were <50 years compared to 18.2% of women; however, more women (19.9%) than men (11.6%) were >80 years. Overall, women were 1.8% less likely to have cTn testing; in patients <50 years, testing was markedly lower in women compared to men [odds ratio, OR (95% confidence intervals, CI) 0.78 (0.70-0.87)]. The odds of cardiac catheterization within 90 days of ED presentation were lower in women [OR, (95% CI) 0.52 (0.44-0.63)]. Even with cardiac CP, 17.7% of women versus 32.7% of men had cardiac catheterization. In men and women presenting to the ED with ischemic CP, cTn testing overall is similar except among young women under 50 years old, where it is markedly lower. Women undergo less cardiac catheterization, irrespective of CP type.

Can a pulse oxygen saturation of 95% to 96% help predict further vital sign destabilization in school-aged children?: A retrospective observational study.

To determine whether a peripheral capillary oxygen saturation (SpO2) of 95% to 96% should be considered “nonurgent” in school-aged children, as suggested by the Canadian Emergency Department Triage and Acuity Scale.School-aged children (6–12 years old) with a normal body temperature (36.5–37.4°C) who visited our department between September, 2014 and August, 2015 (n = 4556) were divided into 4 groups based on SpO2: group A: 99% to 100%; group B: 97% to 98%; group C: 95% to 96%; and group D: ≤94%. The heart rate (HR), respiratory rate (RR), and hospitalization rate were compared among the groups, and also between children with SpO2 95% to 96% and matched controls with SpO2 ≥97% (n = 280 each).Among 4556 eligible patients, groups A, B, C, and D comprised 2700 patients (59.3%), 1534 patients (33.6%), 280 patients (6.2%), and 42 patients (0.9%), respectively. The median (interquartile range [IQR]) RR significantly increased with decreasing SpO2 (23 [20–25], 24 [20–26], 24 [23–30], and 30 [24–40] breaths/min in groups A–D, respectively; P < .001). Similarly, the median (IQR) HR significantly increased with decreasing SpO2 (93 [83–104], 98 [87–110], 107 [93–119], and 121 [109–137] bpm, groups A-D, respectively; P < .001). Group D had the highest annual hospital admission rate (18 cases/42 patients, 42.9%). Further, the HR and RR differed significantly between the cases (107 [93–119] bpm; 24 [23–30] breaths/min) and controls (96 [86–106] bpm; 24 [20–28] breaths/min, respectively) (P < .001 and P = .02, respectively).An SpO2 of 95% to 96% among school-aged children should not be considered “nonurgent,” but rather a significant clinical situation that requires early review of HR and RR. Prompt interventions among this group of children will help prevent further destabilization of vital signs, which will, in turn, contribute to decreased healthcare costs.

Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines 2016.

The Canadian Emergency Department Triage and Acuity Scale (CTAS) has been widely adopted in emergency departments (EDs) across Canada and abroad since its initial publication in 1999. CTAS continues to be revised and updated on a continuing basis. In 2001, a paediatric version of the CTAS implementation guidelines was developed and published. With the ongoing improvements in computer technology, the increasing demands for clinical and administrative data and the wider application of information technology in EDs, the Canadian Emergency Department Information Systems (CEDIS) committee published a standardized presenting complaint list in 2003. In 2004, a revision of the adult CTAS guidelines that incorporated the CEDIS complaint list and introduced the concept of modifiers to assist nurses in the assignment of the appropriate acuity level was published. Modifiers were divided into 2 types: first order and second order. First order modifiers are defined as modifiers that are broadly applicable to a wide number of different complaints. These include vital sign modifiers (e.g., respiratory distress, hemodynamic stability, level of consciousness and fever), pain severity (e.g., central v. peripheral and acute v. chronic) and mechanism of injury. Second order modifiers are specific to a limited number of complaints. One example of a second order modifier is low blood sugar (BS) (e.g., “BS < 3 mmol/L and/or symptomatic” is a modifier for 3 complaints, including altered level of consciousness, confusion and hypoglycemia; while “BS < 3 mmol/L and asymptomatic” modifies only 1 complaint: hypoglycemia). A CTAS revisions supplement that displayed the entire CEDIS complaint list and the relevant first and second order modifiers was published (in portable document format [PDF] and Microsoft Excel format). A more sophisticated Excel application, Complaint Oriented Triage (COT) was designed (by B.U. and M.B.) in 2007. COT, along with all CTAS publications and supplementary documents, is accessible online at www.caep.ca/template .asp?id=B795164082374289BBD9C1C2BF4B8D32. In December 2006, a new combined adult and paediatric CTAS educational package was made available to certified instructors and their students. The package is maintained on a password-protected website. Research regarding CTAS continues to be published. Studies looking at reliability and validity of CTAS using computerized decision support systems have been generally

Implementation of the Canadian Emergency Department Triage and Acuity Scale (CTAS) in an Urgent Care Center in Saudi Arabia.

ObjectivesThe objectives of the study is to review and assess the implementation of the applied modified five-level triage and acuity scale triage system in AL-Yarmook Urgent Care Center (UCC), King Abdulaziz Residential City, Riyadh, Saudi Arabia.MethodAn observational cross-sectional study was conducted, where a data collection sheet was designed and distributed to triage nurses. The data collection was done during the triage process and was directly observed by the co-investigator. The triage system was reviewed by measuring three time intervals as quality indicators: time before triage (TBT), time before being seen by physician (TBP), and total length of stay (TLS) taking in consideration the timing of presentation and the level of triage.ResultsA total of 187 patients visiting the UCC during December 2014 were included. There was an almost equal distribution of males 98 (52 %) and females 89 (48 %) with most of the patients being in the age group of 14 years and younger (n = 85, 46 %). The visits of the patients were classified according to the level of triage from patients to be seen immediately by the physician to those who had been triaged out. Overall, 173 patients (92.5 %) were seen by the physician in a timely manner according to triage guidelines, while 14 patients (7.5 %) were not. The mean time was 5.36 min in TBT, 22.6 min in TBP, and 59 min in TLS. The median time to be seen by the physician was significantly greater (p = 0.001) for the urgent cases on the weekends (25 min; IQR, 21,30) as compared to the weekdays (17 min; IQR, 14,21). Generally, the results did not show significant increases in TBT, TBP, the number of patients not seen at the proper time, or referral and admission rates during weekends.ConclusionThe Canadian Emergency Department Triage and Acuity Scale (CTAS) is adaptable to countries beyond Canada and can be implemented successfully. The applied CTAS triage system in Al-Yarmouk UCC in Riyadh, Saudi Arabia, is considered to be well applied. Overall, urgent cases have been seen by physicians in a timely manner according to the triage system, and there was no delay in the management of critical cases which need prompt attention.

Comment on Alquraini et al.: reliability of Canadian Emergency Department Triage and Acuity Scale (CTAS) in Saudi Arabia.

It is very common to examine reliability of triage scales using (weighted) kappa statistics. The point is that weighted kappa has grossly underestimated disagreements by one category and put more emphasis on extreme category disagreements; therefore, low prevalence of critically-ill and non-urgent patients has excluded the effect of extreme categories disagreement from calculated kappa coefficient and also contributed to significant overestimation. As a result, weighted kappa coefficient as an estimate of scale reliability is overestimated by the anchoring effect.

Utility of blood lactate level in triage.

Simple Triage and Rapid Treatment (START) is commonly used at disaster scenes. The Canadian Emergency Department Triage and Acuity Scale (CTAS) is used in urban and rural emergency departments (ED). However, triage is not always accurate or appropriate. The blood lactate level (BLL) is a major biomarker of physical status. We measured BLL using the Lactate Pro-1710 Test Meter in all patients transported to our ED and assessed their correlation with the triage level determined using START and the CTAS. This retrospective study included 510 patients admitted to our ED between January 2011 and July 2012 whose BLL was measured. The patients were classified into triage divisions (green, yellow, red, and black) according to vital signs and chief complaints, and correlations among BLL, triage level, and prognosis were assessed in all groups. Of the total, 62 patients had cardiopulmonary arrest (CPA), 262 had internal pathologies, and 186 had external pathologies. Significant correlations were observed between BLL and both START and CTAS triage. Also BLL was significantly higher in severe patients categorized with START and CTAS (P < 0.0001), especially in the death group when the patients were divided into two groups according to prognosis (P < 0.0001). Two patients categorized yellow with START died during the hospitalization, however BLL of these two patients were high on admission at the ED. BLL could be used to correct the triage level, and decide the priority of treatment and transportation even within the same triage level, thereby avoiding under-triage.

Reliability of Canadian Emergency Department Triage and Acuity Scale (CTAS) in Saudi Arabia.

BackgroundThe Canadian Emergency Department Triage and Acuity Scale (CTAS) is an integral part of the Canadian emergency medicine triaging system. There is growing interest and implementation of CTAS worldwide. However, little is known about its reliability outside Canada. The aim of this study was to determine the reliability agreement of CTAS in a tertiary care emergency center in Saudi Arabia.MethodsTen triage nurses (five senior and five junior nurses) utilized CTAS guidelines to independently assign a triage level for 160 real case-based scenarios. Quadratic weighted kappa statistics were used to measure raters’ agreements.ResultsRaters provided 1600 triage category assignments to case scenarios for analysis. Intra-rater agreement was similar for both senior and junior nurses; for senior nurses (SN1) kappa 0.871 95 % CI (0.840–0.897), and for junior nurses (SN2) kappa 0.871 95 % CI (0.839–0.898). Inter-rater agreement for the SN1 versus SN2 nurses had statistically meaningful agreement across different triage levels (weighted kappa = 0.770) 95 % CI (0.742–0.797).ConclusionsCTAS has good reliability among emergency department (ED) triage nurses in King Abdulaziz Medical City (KAMC), Saudi Arabia. The findings suggest that CTAS might be a reliable instrument when applied in countries outside Canada.

Inter-rater reliability of a computerized presenting-complaint-linked triage system in an urban emergency department.

Triage reliability studies typically use hypothetical scenarios and weighted kappa scores where agreement within one level is considered satisfactory. But if triage category is used to help define ED case-mix groups for comparative or benchmarking processes, agreement on exact triage level and major system involved is important. Our hypothesis was that a computerized menu that links presenting complaints to preferred triage levels (PC-linked triage) would provide high triage reliability. Our objective was to assess inter-rater reliability of PC-linked triage using the Canadian Emergency Department Triage and Acuity Scale (CTAS) in a real-time clinical setting, considering agreement on exact triage level and primary body system involved. On duty triage nurses entered patient presenting complaint and PC-linked triage level as per standard procedure. In a convenience sample of patients, a second nurse, blinded to triage assignment, observed the triage interaction and independently entered presenting complaint and triage level on a dummy terminal. During the study, 15 nurse pairs triaged 266 patients. Study patients matched actual emergency department case mix closely. Triage nurses agreed exactly in 74% of cases and within one level in 94% of cases. The unweighted kappa value was 0.66 (95% confidence interval [CI], 0.60-0.73) and the quadratic weighted kappa value was 0.75 (95% CI, 0.68-0.81). Kappa for agreement on major system involved was 0.80 (95% CI, 0.69-0.91). PC-linked triage has high inter-rater reliability in a real-time clinical setting. PC-linked triage may be useful as one factor in defining case-mix groups for benchmarking and comparative purposes.

Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines

Revisions to the Canadian Emergency Department Triage and Acuity Scale (CTAS) Guidelines

Characteristics of patients and families who make early return visits to the pediatric emergency department.

The primary objective of this study was to identify reasons why parents make early return visits, within 72 hours of discharge from a tertiary care pediatric emergency department (PED). A secondary objective was to investigate associated demographic and diagnostic variables. A survey was conducted with a convenience sample of parents of children returning to the PED within 72 hours of discharge. A chart review was also completed for consented survey participants. Recruitment occurred from September 2005 to August 2006 at the Stollery Children's Hospital, Edmonton, Alberta, Canada. A total of 264 parents were approached to participate. Overall, 231 surveys were returned and 212 (92%) charts were reviewed. The overall rate of early return during the study period was 5.4%. More than half of parents stated that they returned because their child's condition worsened and many parents (66.7%) reported feeling stressed. Patients were typically under 6 years of age (67.4%), and most frequently diagnosed with infectious diseases (38.0%). Patients triaged with the Canadian Emergency Department Triage and Acuity Scale (CTAS) as CTAS 2 (emergent) for initial visits were more likely to be admitted on return, regardless of age (P < 0.001). Variables associated with early returns included young age, diagnosis, triage acuity, and parental stress. Future variable definition should include a deeper exploration of modifiable factors such as parental stress and patient education. These next steps may help direct interventions and resources to address needs in this group and possibly pre-empt the need to return.

388 Validity of the Canadian Emergency Department Triage Acuity Scale Respiratory Rate and Pulse Rate Reference Ranges When Applied to a Chinese Population

Introduction: A previous study found that about half of the measured blood pressure, pulse rate and respiratory rate values in a population of healthy Chinese pre-school and school aged children fell outside the Advanced Pediatric Life Support (APLS) aged-based vital signs reference range.

The effect of a charted history of depression on emergency department triage and outcomes in patients with acute myocardial infarction

Patients with acute myocardial infarction may have worse outcomes if they also have a history of depression. The early management of acute myocardial infarction is known to influence outcomes, and patients with a coexisting history of depression may be treated differently in the emergency department than those without one. Our goal was to determine whether having a charted history of depression was associated with a lower-priority emergency department triage score and worse performance on quality-of-care indices. We conducted a retrospective population-based cohort analysis involving patients with acute myocardial infarction admitted to 96 acute care hospitals in the province of Ontario from April 2004 to March 2005. We calculated the adjusted odds of low-priority triage (Canadian Emergency Department Triage and Acuity Scale score of 3, 4 or 5) for patients with acute myocardial infarction who had a charted history of depression. We compared these odds with those for patients having a charted history of asthma or chronic obstructive pulmonary disease (COPD). Secondary outcome measures were the odds of meeting benchmark door-to-electrocardiogram, door-to-needle and door-to-balloon times. Of 6784 patients with acute myocardial infarction, 680 (10.0%) had a past medical history of depression documented in their chart. Of these patients, 39.1% (95% confidence interval [CI] 35.3%-42.9%) were assigned a low-priority triage score, as compared with 32.7% (95% CI 31.5%-33.9%) of those without a charted history of depression. The adjusted odds of receiving a low-priority triage score with a charted history of depression were 1.26 (p = 0.01) versus 0.88 (p = 0.23) with asthma and 1.12 (p = 0.24) with COPD. For patients with a charted history of depression, the median door-to-electrocardiogram time was 20.0 minutes (v. 17.0 min for the rest of the cohort), median door-to-needle time was 53.0 (v. 37.0) minutes, and median door-to-balloon time was 251.0 (v. 110.0) minutes. The adjusted odds of missing the benchmark time with a charted history of depression were 1.39 (p < 0.001) for door-to-electrocardiogram time, 1.62 (p = 0.047) for door-to-needle time and 9.12 (p = 0.019) for door-to-balloon time. Patients with acute myocardial infarction who had a charted history of depression were more likely to receive a low-priority emergency department triage score than those with other comorbidities and to have worse associated performance on quality indicators in acute myocardial infarction care.

Canadian Emergency DepartmentTriage and Acuity Scale: implementation in a tertiary care center in Saudi Arabia

BackgroundThe Canadian Emergency Department Triage and Acuity Scale (CTAS) is a well recognized and validated triage system that prioritizes patient care by severity of illness. The aim of this study was to describe the results of Emergency Department (ED) waiting times after the implementation of the CTAS in a major tertiary care hospital emergency department outside of Canada.MethodsA total of 1206 charts were randomly selected and retrospectively reviewed for triage performance. The indicators were: time to triage, triage duration, waiting time to be evaluated by a physician, and proportion of patients who left without being seen by a physician. Waiting times were stratified by triage level and reported as fractile response rates.ResultsThe approximate time to triage was ≤ 10 minutes for 71% and ≤ 15 minutes for 82.8% of the patients. Fifty-three percent (53.5%) completed their triage process within 5 minutes. Waiting times evaluated by a physician was 100% within CTAS time objectives in category I patients, however, this was not the case for the other 4 categories. The overall left without being seen (LWBS) rate was 9.8%; 11.9% were in Level III, 20.3% in Level IV, and 67.8% in Level V. Median length of stay (LOS) was 144 minutes for the study sample as a whole.ConclusionThe CTAS may be adapted, with achievable objectives, in hospitals outside Canada as well. Time to see physician, total LOS, and LWBS are effective markers of ED performance and the quality of triage. Registration-to-physician time (RTP) and LOS profiles, stratified by triage level, are essential indicative markers for ED performance and should be used in improving patients flow through collaborative efforts.