Canadian Triage And Acuity Scale Score Research Articles

Repeatability, reproducibility, and diagnostic accuracy of a commercial large language model (ChatGPT) to perform emergency department triage using the Canadian triage and acuity scale.

The release of the ChatGPT prototype to the public in November 2022 drastically reduced the barrier to using artificial intelligence by allowing easy access to a large language model with only a simple web interface. One situation where ChatGPT could be useful is in triaging patients arriving to the emergency department. This study aimed to address the research problem: "can emergency physicians use ChatGPT to accurately triage patients using the Canadian Triage and Acuity Scale (CTAS)?". Six unique prompts were developed independently by five emergency physicians. An automated script was used to query ChatGPT with each of the 6 prompts combined with 61 validated and previously published patient vignettes. Thirty repetitions of each combination were performed for a total of 10,980 simulated triages. In 99.6% of 10,980 queries, a CTAS score was returned. However, there was considerable variations in results. Repeatability (use of the same prompt repeatedly) was responsible for 21.0% of overall variation. Reproducibility (use of different prompts) was responsible for 4.0% of overall variation. Overall accuracy of ChatGPT to triage simulated patients was 47.5% with a 13.7% under-triage rate and a 38.7% over-triage rate. More extensively detailed text given as a prompt was associated with greater reproducibility, but minimal increase in accuracy. This study suggests that the current ChatGPT large language model is not sufficient for emergency physicians to triage simulated patients using the Canadian Triage and Acuity Scale due to poor repeatability and accuracy. Medical practitioners should be aware that while ChatGPT can be a valuable tool, it may lack consistency and may frequently provide false information.

Development of a machine learning-based acuity score prediction model for virtual care settings

ObjectiveHealthcare is increasingly digitized, yet remote and automated machine learning (ML) triage prediction systems for virtual urgent care use remain limited. The Canadian Triage and Acuity Scale (CTAS) is the gold standard triage tool for in-person care in Canada. The current work describes the development of a ML-based acuity score modelled after the CTAS system.MethodsThe ML-based acuity score model was developed using 2,460,109 de-identified patient-level encounter records from three large healthcare organizations (Ontario, Canada). Data included presenting complaint, clinical modifiers, age, sex, and self-reported pain. 2,041,987 records were high acuity (CTAS 1–3) and 416,870 records were low acuity (CTAS 4–5). Five models were trained: decision tree, k-nearest neighbors, random forest, gradient boosting regressor, and neural net. The outcome variable of interest was the acuity score predicted by the ML system compared to the CTAS score assigned by the triage nurse.ResultsGradient boosting regressor demonstrated the greatest prediction accuracy. This final model was tuned toward up triaging to minimize patient risk if adopted into the clinical context. The algorithm predicted the same score in 47.4% of cases, and the same or more acute score in 95.0% of cases.ConclusionsThe ML algorithm shows reasonable predictive accuracy and high predictive safety and was developed using the largest dataset of its kind to date. Future work will involve conducting a pilot study to validate and prospectively assess reliability of the ML algorithm to assign acuity scores remotely.

LO21: Consistency of CTAS scores by presenting complaint pre and post eCTAS implementation in 35 emergency departments across Ontario

Introduction: eCTAS is a real time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The tool dynamically calculates a recommended CTAS score based on the presenting complaint, vital signs and selected clinical modifiers. The primary objective was to assess consistency of CTAS score distributions across 35 emergency departments (EDs) by 16 presenting complaints pre and post eCTAS implementation. Methods: This retrospective cohort study used population-based administrative data from January 2016 to December 2018 from all hospital EDs in Ontario that had implemented eCTAS with at least 9 months of data. Following a 3-month stabilization period, we compared data for 6 months post-eCTAS implementation to the same 6-month period the previous year (pre-implementation) to account for potential seasonal variation, patient volume and case-mix. We included triage encounters of adult (≥18 years) patients if they had one of 16 pre-specified high-volume, presenting complaints. A paired-samples t-test was used to determine consistency by estimating the absolute difference in CTAS distribution for each presenting complaint, by each hospital, pre and post eCTAS implementation, compared to the overall average of the 35 EDs. Results: There were 183,231 triage encounters in the pre-eCTAS cohort and 179,983 in the post-eCTAS cohort from 35 EDs across the province. Triage scores were more consistent with the overall average after eCTAS implementation in 6 (37.5%) presenting complaints: chest pain (cardiac features) (p < 0.001), extremity weakness/symptoms of cerebrovascular accident (p < 0.001), fever (p < 0.001), shortness of breath (p < 0.001), syncope (p = 0.02), and hyperglycemia (p = 0.03). Triage consistency was similar pre and post eCTAS implementation for the presenting complaints of altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self-harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication or vertigo. Conclusion: A standardized, electronic approach to performing triage assessments increased consistency in CTAS scores across many, but not all, high-volume CEDIS complaints. This does not reflect triage accuracy, as there are no known benchmarks for triage accuracy. Improvements in consistency were greatest for sentinel presenting complaints with a minimum allowable CTAS score.

MP15: Predictors of emergency department opioid use and variability of prescribing practices in a large multicenter Canadian cohort

Introduction: Emergency department (ED) opioid prescribing has been linked to long-term use and dependence. Anecdotally, significant opioid practice variability exists between physicians and institutions, but this is poorly defined. Our objective was to collate and analyze multicenter data looking at predictors of ED opioid use and to identify potential areas for opioid stewardship. Methods: We linked administrative and computerized physician order entry (CPOE) data from all four ED's within our municipality over a one-year period. Eligible patients included those with a Canadian Triage and Acuity Scale (CTAS) pain complaint or an arrival numeric rating scale (NRS) pain score of greater than 3/10. Patients with missing demographic or chief complaint data were excluded. Multiple imputation was used for missing NRS pain scores. We performed descriptive analyses of opioid-treated and non-treated patients, followed by a multivariable logistic regression to identify predictors of ED opioid administration. Results: A total of 129,547 patients were studied. The mean age was 47.4 years and 55.4% were female. The median pain score was 6.6 in the no-opioid group and 8 in the opioid group. The most common pain categories were abdominal pain (23%), trauma (18.2%) and chest pain (15.3%). Overall, opioids were prescribed to 34% of patients. The most common CTAS score was CTAS 3 (44%), CTAS 1-2 42%) and CTAS 4-5 (13.9%). Multivariable predictors of opioid-use included the need for admission (adjusted OR 6.57; CI = 6.34-6.79), NRS pain score (aOR 1.24 per unit increase, CI 1.23-1.25), higher numerical CTAS score (aOR 0.89 per unit increase, CI 0.87-0.91), and chief complaints of back (aOR 7.69, CI 7.1-8.1), abdominal (aOR 5.9, CI 5.6-6.2), and flank pain (OR 3.8, CI 3.5-4). Oral opioids were prescribed in 39.8% of back pain presentations and 18.5% received IV opioids. Increasing age was a predictor but sex was not. There were significant institutional differences in opioid prescribing rates, with Hospital B being the least likely to prescribe opioids (aOR 0.82, CI 0.80-0.85) followed by Hospital C (aOR 0.83, CI 0.79-0.86) compared to the reference standard of Hospital A. Hospital D was most likely to prescribe opioids (aOR 1.32, CI 1.27-1.37). Conclusion: Predictors of ED opioid use were characterized using multicenter administrative data. Future research should seek to describe the physician- and site-level factors driving regional variation in opioid-based pain treatment.

Consistency of triage scores by presenting complaint pre- and post-implementation of a real-time electronic triage decision support tool.

ObjectiveeCTAS is a real‐time electronic decision‐support tool designed to standardize the application of the Canadian Triage and Acuity Scale (CTAS). This study addresses the variability of CTAS score distributions across institutions pre‐ and post‐eCTAS implementation.MethodsWe used population‐based administrative data from 2016–2018 from all emergency departments (EDs) that had implemented eCTAS for 9 months. Following a 3‐month stabilization period, we compared 6 months post‐eCTAS data to the same 6 months the previous year (pre‐eCTAS). We included triage encounters of adult (≥17 years) patients who presented with 1 of 16 pre‐specified, high‐volume complaints. For each ED, consistency was calculated as the absolute difference in CTAS distribution compared to the average of all included EDs for each presenting complaint. Pre‐eCTAS and post‐eCTAS change scores were compared using a paired‐samples t‐test. We also assessed if eCTAS modifiers were associated with triage consistency.ResultsThere were 363,214 (183,231 pre‐eCTAS, 179,983 post‐eCTAS) triage encounters included from 35 EDs. Triage scores were more consistent (P < 0.05) post‐eCTAS for 6 (37.5%) presenting complaints: chest pain (cardiac features), extremity weakness/symptoms of cerebrovascular accident, fever, shortness of breath, syncope, and hyperglycemia. Triage consistency was similar pre‐ and post‐eCTAS for altered level of consciousness, anxiety/situational crisis, confusion, depression/suicidal/deliberate self‐harm, general weakness, head injury, palpitations, seizure, substance misuse/intoxication, and vertigo. Use of eCTAS modifiers was associated with increased triage consistency.ConclusionseCTAS increased triage consistency across many, but not all, high‐volume presenting complaints. Modifier use was associated with increased triage consistency, particularly for non‐specific complaints such as fever and general weakness.

Interrater Reliability, Accuracy, and Triage Time Pre- and Post-implementation of a Real-Time Electronic Triage Decision-Support Tool

The electronic Canadian Triage and Acuity Scale (eCTAS) is a real-time electronic triage decision-support tool designed to improve patient safety and quality of care by standardizing the application of the Canadian Triage and Acuity Scale (CTAS). The objective of this study is to determine interrater agreement of triage scores pre- and post-implementation of eCTAS. This was a prospective, observational study conducted in 7 emergency departments (EDs), selected to represent a mix of triage documentation practices, hospital types, and patient volumes. A provincial CTAS auditor observed triage nurses in the ED pre- and post-implementation of eCTAS and assigned an independent CTAS score in real time. Research assistants independently recorded triage time. Interrater agreement was estimated with κ statistics with 95% confidence intervals (CIs). A total of 1,491 individual triage assessments (752 pre-eCTAS, 739 post-implementation) were audited during 42 7-hour triage shifts (21 pre-eCTAS, 21 post-implementation). Exact modal agreement was achieved for 567 patients (75.4%) pre-eCTAS compared with 685 patients (92.7%) triaged with eCTAS. With the auditor's CTAS score as the reference, eCTAS significantly reduced the number of patients over-triaged (12.0% versus 5.1%; Δ 6.9; 95% CI 4.0 to 9.7) and under-triaged (12.6% versus 2.2%; Δ 10.4; 95% CI 7.9 to 13.2). Interrater agreement was higher with eCTAS (unweighted κ 0.89 versus 0.63; quadratic-weighted κ 0.93 versus 0.79). Median triage time was 312 seconds (n=3,808 patients) pre-eCTAS and 347 seconds (n=3,489 patients) with eCTAS (Δ 35 seconds; 95% CI 29 to 40 seconds). A standardized, electronic approach to performing triage assessments improves both interrater agreement and data accuracy without substantially increasing triage time.

The impact of pediatric emergency department crowding on patient and health care system outcomes: a multicentre cohort study.

Emergency department overcrowding has been associated with increased odds of hospital admission and mortality after discharge from the emergency department in predominantly adult cohorts. The objective of this study was to evaluate the association between crowding and the odds of several adverse outcomes among children seen at a pediatric emergency department. We conducted a retrospective cohort study involving all children visiting 8 Canadian pediatric emergency departments across 4 provinces between 2010 and 2014. We analyzed the association between mean departmental length of stay for each index visit and hospital admission within 7 days or death within 14 days of emergency department discharge, as well as hospital admission at index visit and return visits within 7 days, using mixed-effects logistic regression modelling. A total of 1 931 465 index visits occurred across study sites over the 5-year period, with little variation in index visit hospital admission or median length of stay. Hospital admission within 7 days of discharge and 14-day mortality were low across provinces (0.8%-1.5% and < 10 per 100 000 visits, respectively), and their association with mean departmental length of stay varied by triage categories and across sites but was not significant. There were increased odds of hospital admission at the index visit with increasing departmental crowding among visits triaged to Canadian Triage and Acuity Scale (CTAS) score 1-2 (odds ratios [ORs] ranged from 1.01 to 1.08) and return visits among patients with a CTAS score of 4-5 discharged at the index visit at some sites (ORs ranged from 1.00 to 1.06). Emergency department crowding was not significantly associated with hospital admission within 7 days of the emergency department visit or mortality in children. However, it was associated with increased hospital admission at the index visit for the sickest children, and with return visits to the emergency department for those less sick.

LO81: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score pre and post implementation of eCTAS

Introduction: In addition to its clinical utility, the Canadian Triage and Acuity Scale (CTAS) has become an administrative metric used by governments to estimate patient care requirements, emergency department (ED) funding and workload models. The electronic Canadian Triage and Acuity Scale (eCTAS) initiative aims to improve patient safety and quality of care by establishing an electronic triage decision support tool that standardizes that application of national triage guidelines across Ontario. The objective of this study was to evaluate triage times and score agreement in ED settings where eCTAS has been implemented. Methods: This was a prospective, observational study conducted in 7 hospital EDs, selected to represent a mix of triage processes (electronic vs. manual), documentation practices (electronic vs. paper), hospital types (rural, community and teaching) and patient volumes (annual ED census ranged from 38,000 to 136,000). An expert CTAS auditor observed on-duty triage nurses in the ED and assigned independent CTAS in real time. Research assistants not involved in the triage process independently recorded triage time. Interrater agreement was estimated using unweighted and quadratic-weighted kappa statistics with 95% confidence intervals (CIs). Results: 1491 (752 pre-eCTAS, 739 post-implementation) individual patient CTAS assessments were audited over 42 (21 pre-eCTAS, 21 post-implementation) seven-hour triage shifts. Exact modal agreement was achieved for 567 (75.4%) patients pre-eCTAS, compared to 685 (92.7%) patients triaged with eCTAS. Using the auditor's CTAS score as the reference standard, eCTAS significantly reduced the number of patients over-triaged (12.0% vs. 5.1%; Δ 6.9, 95% CI: 4.0, 9.7) and under-triaged (12.6% vs. 2.2%; Δ 10.4, 95% CI: 7.9, 13.2). Interrater agreement was higher with eCTAS (unweighted kappa 0.89 vs 0.63; quadratic-weighted kappa 0.91 vs. 0.71). Research assistants captured triage time for 3808 patients pre-eCTAS and 3489 post implementation of eCTAS. Median triage time was 312 seconds pre-eCTAS and 347 seconds with eCTAS (Δ 35 seconds, 95% CI: 29, 40 seconds). Conclusion: A standardized, electronic approach to performing CTAS assessments improves both clinical decision making and administrative data accuracy without substantially increasing triage time.

P094: Evaluation of the National Early Warning Score (NEWS) to guide the orientation of patients with sepsis in the emergency department

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

P158: Sensitivity analysis of CTAS temperature modifier in the emergency department

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

LO70: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score pre and post implementation of eCTAS

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

LO09: Assessing the ability of emergency department patients to self-triage by using an electronic questionnaire: a pilot study

Introduction: The process of triage is used to prioritize the care of patients arriving in the emergency department (ED). To our knowledge, self-triage has not been previously studied in the general emergency department (ED) setting. In an attempt to test the feasibility of implementing this in the ED, we sought to assess the ability of ED patients to triage themselves using an electronic questionnaire. Methods: This was a prospective observational study. An iPad-based questionnaire was designed with a series of ‘yes’ or ‘no’ answers related to common chief complaints. A score corresponding to a Canadian Triage and Acuity Scale (CTAS) category was assigned based on their answers, without the knowledge of patients or ED staff. These scores were subsequently compared to the official CTAS score assigned by triage nurses. A convenience sample of ambulatory patients arriving at the ED were enrolled over a four week period. Patients arriving by ambulance were excluded. We also sought to assess patients’ ability to predict their ultimate disposition. Results: A total of 492 patients were enrolled. The mean age of enrolled patients was 43.9. Of enrolled patients, 56 (11.4%) were under 20 years old, 168 (34.1%) between ages 20-39, 116 (23.6%) between ages 40-59 and 152 (30.9%) older than 60 years. We had 245 (49.8%) patients identify as male. Patient-determined CTAS scores were as follows: 146 CTAS 1 (26.7%), 66 CTAS 2 (13.4%), 176 CTAS 3 (35.8%) and 104 CTAS 4 and 5 (21.1%). Formal triage CTAS scores were: 47 CTAS 2 (9.6%), 155 CTAS 3 (31.5%), and 290 CTAS 4 and 5 (59%). With our survey tool, 22.2% of patients matched their official triage scores. We found that that 69.9% of participants over-estimated their CTAS score while 7.9% underestimated it. Two hundred and three patients (41.3%) felt that they needed to be admitted. In fact, 73 patients (17.3%) were admitted to hospital. Conclusion: Using an electronic questionnaire, ambulatory patients frequently overestimated the acuity of their presenting complaint. Patients were also not unable to accurately predict their disposition. Further study of different approaches to self-triage is needed before possible implementation in EDs.

LO75: Interrater agreement and time it takes to assign a Canadian Triage and Acuity Scale score in 7 emergency departments

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

LO50: Headache presentations to emergency departments in Alberta: understanding investigative approaches

Introduction: Headaches are a common emergency department (ED) presentation. The objective of this study was to characterize headache presentations in Alberta over a five-year period and explore the proportion of patients with potentially severe pathology. Methods: Administrative health data for Alberta (years 2011-2015) were obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (&amp;gt;17 years) headache presentations (ICD-10-CA: G43, G44, R51). Patients with a primary or secondary diagnosis code of headache were eligible for inclusion in the study. Exclusions were made using the following criteria: 1) sites without computed tomography (CT) scanners; 2) presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1; 3) patients with trauma or external mechanism of injury (e.g., ICD-10-CA codes S,T,V,W,X,Y); and 4) presentations receiving an enhanced/contrast CT (head). NACRS data were linked with a provincial diagnostic imaging data. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, 98,333 presentations were made by 66,970 patients (~0.3 presentations per patient per year; equivalent to one presentation every 3.4 years). Headache presentations increased from 15,643 in 2011 to 21,636 in 2015. The median age was 38 years (IQR: 29, 51 years); more patients were female (69.3%), had a CTAS score of 3 (55%) and arrived at the ED without ambulance (90.3%). The majority of patients had a primary ED diagnosis of headache (88%) and the most common co-diagnosis was benign hypertension (2.8%). Additional diagnoses indicating severe or pathological headaches, included: stroke (0.63%), subarachnoid hemorrhage (0.43%), infection (i.e., meningitis) (0.11%), and other brain hemorrhages (0.08%). Overall, the ED management of approximately 25% of presentations involved a head CT. Most patients were discharged from the ED (89.4%) after a median length of stay of 3.5 hours (IQR: 2.1, 5.2 hours). Conclusion: Headache-related ED presentations are increasing in Alberta, yet few severe/pathological diagnoses are being identified. Efforts to ensure appropriateness of head CT ordering could reduce exposure to ionizing radiation, improve patient flow and reduce health care costs; this imaging represents a target for future interventions.

MP12: Acute asthma presentations to emergency departments in Alberta: an epidemiological analysis of presentations

Introduction: Asthma is a chronic condition and exacerbations are a common reason for emergency department (ED) presentations across Canada. The objective of this study was to characterize and describe acute asthma presentations over a five-year period. Methods: Administrative health data for Alberta from 2011-2015 was obtained from the National Ambulatory Care Reporting System (NACRS) for all adult (&amp;gt;17 years) acute asthma (ICD-10-CA: J45) ED presentations. All presentations to an Alberta ED with a primary or secondary diagnosis of acute asthma were eligible for inclusion. Presentations with a Canadian Triage and Acuity Scale (CTAS) score of 1 were excluded. Data from NACRS were linked with a provincial diagnostic imaging database. Data are reported as means and standard deviation (SD), medians and interquartile range (IQR) or proportions, as appropriate. Results: From 2011-2015, a total of 51,269 (~10,000/year) acute asthma presentations were made by 34,481 patients (~0.3 presentations per patient per year). The median age was 35 years (IQR: 25, 49 years) and more patients were female (57.2%). Few patients arrived to the ED by ambulance (6.5%) and the most frequent CTAS score was 3 (43.5%). The majority of these patients (77%) had a primary diagnosis of asthma in the ED. Differences were explored between those with a primary asthma diagnosis and those with a secondary diagnosis (e.g., ambulance arrival, length of stay, hospital admission, etc.). Although differences were statistically significant, no clinically relevant differences were identified. Patients with asthma most frequently had a co-diagnosis of acute upper respiratory infection (6.2%); other co-diagnoses included bronchitis (4.7%), pneumonia (3.7%), heart failure (0.18%), pulmonary embolism (0.15%), and pneumothorax (0.03%). For 39.3% of patients, ED management included chest x-ray. The majority of patients were discharged from the ED (92.2%) following a median length of stay of 2.2 hours (IQR: 1.2, 3.8 hours). Conclusion: Acute asthma remains an important ED presentation in Alberta and the absolute frequency of presentations has remained relatively stable over the past five years. Frequency of chest x-ray ordering is high and represents a target for future interventions to reduce ionizing radiation exposure, improve patient flow and reduce healthcare costs.

Quality of febrile neutropenia management in a regional cancer center emergency department.

104 Background: ASCO's current guidelines for febrile neutropenia (FN) management support antibiotic administration within one hour of presentation to the emergency department (ED). Prompt initiation of antibiotic therapy is vital to decrease the likelihood of adverse outcomes. Many studies, however, have reported significant delays in antibiotic initiation with mean wait times far exceeding ASCO's guidelines. We aimed to assess the quality of FN management at a regional cancer centre ED. Methods: Patients undergoing chemotherapy who visited the ED at the Peel Regional Cancer Center in Ontario, Canada between 04/12 - 03/13 were identified using electronic medical records. Patients were excluded if there was no record of chemotherapy delivery within 30 days prior to ED visit. ICD-10 codes and chart data were used to identify patients who had presented for either fever or infection. The primary outcome measures were three major quality of health indicators; time to assessment by a physician, Canadian Triage and Acuity Scale (CTAS) score, and time to initiation of intravenous antibiotics. Results: In total 239 records were included in the analysis. CTAS score was concordant with recommendation for FN (level 1-2) in 85% of patients and did not vary based on primary cancer site (p = 0.17). The mean time to physician assessment was 97.2 min and the mean time to initiation of IV antibiotics was 194.7 min. Overall, 14.6% of patients received their first dose of antibiotic therapy within the recommended 1 hour window. Conclusions: Our audit identified a large margin for improvement in the time to initiation of antibiotic therapy for chemotherapy patients with suspected FN. Prompt recognition and initiation of standardized treatment pathways for FN in the ED may improve the time to initiation of antibiotic therapy. In an attempt to address this gap in quality we have developed and distributed a standardized wallet-sized fever card to all patients receiving cytotoxic chemotherapy within our regional cancer program. This card contains information pertaining to the current chemotherapy treatment and recommended ED treatment protocols for FN. An evaluation of the impact of these cards is ongoing.

Reliability of the Canadian Triage and Acuity Scale: interrater and intrarater agreement from a community and an academic emergency department

The Canadian Triage and Acuity Scale (CTAS) is a five-level triage tool that is used to help prioritize the order in which emergency department (ED) patients should be seen. The objectives of this study were to determine the interrater and intrarater agreement of the 2008 CTAS guideline revisions by triage nurses and to compare agreement between triage nurses working in a small community ED and an academic ED. Seventy-eight triage nurses assigned CTAS scores and free-text presenting complaints for 10 paper-based case scenarios. For five scenarios, the CTAS score should have remained unchanged from previous guidelines, whereas the other five scenarios should have been triaged differently based on the 2008 CTAS first-order modifiers. Thirty-three participants repeated the questionnaire 90 days later, and intrarater agreement was measured. There was a higher level of agreement (κ = 0.73; 95% CI 0.68-0.79) for the five case scenarios, which relied on the older 2004 guidelines compared to the scenarios where the 2008 guidelines would have suggested a different triage level (κ = 0.50; 95% CI 0.42-0.59). For the 10 case scenarios analyzed, the free-text presenting complaints matched the Canadian Emergency Department Information System (CEDIS) list 90.1% of the time (κ = 0.80; 95% CI 0.76-0.84). The reliability of CTAS scoring by academic and community ED nurses was relatively good; however, the application of the 2008 CTAS revisions appears less reliable than the 2004 CTAS guidelines. These results may be useful to develop educational materials to strengthen reliability and validity for triage scoring using the 2008 CTAS guideline revisions.

Patients' satisfaction and wait times at Guelph General Hospital Emergency Department before and after implementation of a process improvement project

A process improvement program (PIP) was implemented in the emergency department (ED) at Guelph General Hospital in July 2009. The purpose of this study was to examine patients' satisfaction and wait times by level of Canadian Triage and Acuity Scale (CTAS) score before and 6 months after implementation of this program. Two samples were recruited: one was recruited before implementation of the PIP, January to June 2009 (T1), and one was recruited 6 months after implementation, January to June 2010 (T2). Patients were contacted by telephone to administer a survey including patient satisfaction with quality of care. Time to physician initial assessment, numbers left without being seen, and length of stay (LOS) were obtained from hospital records to compare wait times before and 6 months after implementation of the PIP. Patients (n = 301) reported shorter wait times after implementation (e.g., 12% reported seeing a physician right away at T1 compared to 29% at T2). Time to physician initial assessment improved for patients with CTAS scores of III, IV, and V (average decrease from 2.1 to 1.7 hours), fewer patients (n = 425) left without being seen after implementation, and the mean and 90th percentile of LOS decreased for all patients except the mean LOS for discharged patients with a CTAS score of I. Total time spent in the ED for admitted patients decreased from 11.11 hours in the 2009 period to 9.95 in the 2010 period, and for nonadmitted patients, the total time decreased from 3.94 to 3.29 hours. The overall satisfaction score improved from a mean of 3.17 to 3.4 (of 4; p < 0.001). Implementation of the ED PIP corresponded with decreased wait times, increased patient satisfaction, and improved patient flow for patients with CTAS scores of III, IV, and V.

The validity of the canadian triage and acuity scale in predicting resource utilization and the need for immediate life-saving interventions in elderly emergency department patients

BackgroundWe evaluated the validity of the Canadian Triage and Acuity Scale (CTAS) in elderly emergency department (ED) patients. In particular, we examined the sensitivity and specificity of the CTAS for identifying elderly patients who received an immediate life-saving intervention in the ED.MethodsWe reviewed the medical records of consecutive patients who were 65 years of age or older and presented to a single academic ED within a three-month period. The CTAS triage scores were compared to actual patient course, including disposition, discharge outcome and resource utilization. We calculated the sensitivity and specificity of the CTAS triage for identifying patients who received an immediate intervention.ResultsOf the 1903 consecutive patients who were ≥ 65 years of age, 113 (5.9%) had a CTAS level of 1, 174 (9.1%) had a CTAS level of 2, 1154 (60.6%) had a CTAS level of 3, 347 (18.2%) had a CTAS level of 4, and 115 (6.0%) had a CTAS level of 5. As a patient's triage score increased, the severity (such as mortality and intensive care unit admission) and resource utilization increased significantly. Ninety-four of the patients received a life-saving intervention within an hour following their arrival to the ED. The CTAS scores for these patients were 1, 2 and 3 for 46, 46 and 2 patients, respectively. The sensitivity and specificity of a CTAS score of ≤ 2 for identifying patients for receiving an immediate intervention were 97.9% and 89.2%, respectively.ConclusionsThe CTAS is a triage tool with high validity for elderly patients, and it is an especially useful tool for categorizing severity and for recognizing elderly patients who require immediate life-saving intervention.

Predictors of Hospital Admission for Chronic Obstructive Pulmonary Disease Exacerbations in Canadian Emergency Departments

The objective was to examine predictors of hospital admission among adults presenting to Canadian emergency departments (EDs) for acute exacerbations of chronic obstructive pulmonary disease (COPD). Current acute treatment approaches and outcomes 2 weeks after the ED visit are also described. Subjects, aged > or =35 years presenting with COPD exacerbations to 16 EDs across Canada, underwent a structured in-ED interview and a telephone interview 2 weeks later. Of 501 study patients, 247 (49.3%; 95% confidence interval [CI] = 44.9% to 53.6%) were admitted. Admitted patients were older, were more often former smokers, and had more admissions for COPD during the past 2 years. They also reported more days of activity limitation and use of inhaled beta(2)-agonists in the previous 24 hours. Canadian Triage and Acuity Scale (CTAS), respiratory rate (RR), and airflow obstruction were more severe in the hospitalized group. Most of the patients received inhaled beta(2)-agonists, anticholinergics, oral corticosteroids (CS), and antibiotics; hospitalized patients received more aggressive treatments. The median ED length of stay (LOS) of admitted patients was 13.1 hours (interquartile range [IQR] = 7.4-23.0) compared to 5.6 hours (IQR = 4.2-8.4) in discharged patients. Admission was associated with at least two COPD admissions in the past 2 years (odds ratio [OR] = 2.10; 95% CI = 1.24 to 3.56), receiving oral CS for COPD (OR = 1.72; 95% CI = 1.08 to 2.74), having a CTAS score of 1-2 (OR = 2.04; 95% CI = 1.33 to 3.12), and receiving adjunct ED treatments (OR = 3.95; 95% CI = 2.45 to 6.35). Use of EDs for usual COPD care was associated with a reduced risk of admission (OR = 0.43; 95% CI = 0.28 to 0.66). Exacerbations of COPD in Canadian EDs result in prolonged ED stays and approximately 50% hospitalization despite aggressive acute treatment approaches. Historical, severity, and treatment-related factors were strongly associated with hospital admission. Validation of these results should be completed prior to widespread use.