Canadian Triage Research Articles

Role of Venous Blood Gase (VBG) Analysis in Patient Triage in the Adult Emergency Department

Background: In emergency and critical care settings, can a venous blood gas analysis improve clinical decision-making and patient outcomes? Methods: This is a cross-sectional study, conducted between January and June 2022 at a tertiary hospital in Saudi Arabia. Results: A total of 100 patients were included, using a convenience sample technique. Their mean age was 54 years, and theirmain chief complaints were shortness of breath (30%), abdominal pain (15%), and altered level of consciousness (14%). The venous blood gas (VBG) result was abnormal in 86 patients, and predicted the need for early intervention in 69 patients (69.7%). A significant association was found between patients requiring early intervention and those with an abnormal VBG (p=0.0005). Furthermore, the VBG results changed the Canadian Triage and Acuity Scale (CTAS) level in 32 patients (33.68%). A logistic regression analysis revealed that pre-testing factors such as age, gender, comorbidities, and chief complaints were not predictors of VBG results, the need for early intervention, or altered CTAS level. Conclusion: Our study concludes that VBG analysis can play an important role in patient triage in the emergency department (ED), allowing for earlier intervention and potentially improving outcomes.

Prevalence and predictors of elder abuse among older adults attending emergency departments: a prospective cohort study.

Elder abuse is associated with impaired physical and psychological health. It is, however, rarely identified in emergency departments (EDs). The objective was to determine the prevalence and the predictors of elder abuse among older adults visiting EDs. This prospective cohort study was conducted in eight Canadian EDs between May and August 2021. Patients were eligible if they were ≥ 65years old, oriented to time, and with a Canadian Triage and Acuity Scale score 3, 4 or 5. In a private setting, participants were questioned directly about abuse as part of a larger questionnaire exploring ten non-medical problems. We used multivariable logistic regression to identify predictors of elder abuse. A total of 1061 participants were recruited (mean age: 77.1 (SD 7.6) years, female sex: 55.7%, lived alone: 42.5%). Patients mostly attended EDs for pain (19.6%), neurologic (11.3%) or cardiovascular (8.4%) symptoms. The most frequent pre-existing comorbidities were hypertension (67.2%), mental health conditions (33.3%) and cardiac insufficiency (29.6%). Mobility issues outside (41.0%) or inside their home (30.7%) and loneliness (29.4%) were also frequent. Fifty-four (5.1%) participants reported elder abuse, of which 34.3% were aware of available community-based resources. Identified predictors of elder abuse were female sex (OR 2.8 [95%CI 1.4; 5.6]), financial difficulties (OR 3.6 [95%CI 1.8; 7.3]), food insecurity (OR 2.7 [95%CI 1.2; 5.6]), need for a caregiver (OR 2.7 [95%CI 1.5; 5.0]) and at least one pre-existing mental health condition (OR 2.6 [95%CI 1.4; 4.9]). When questioned directly, 5.1% of older adults attending EDs reported experiencing abuse. Female sex, functional impairment, social vulnerability, and mental health comorbidities are associated with elder abuse. Given its importance and relatively high prevalence, ED professionals should have a low threshold to ask directly about elder abuse.

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.

Knowledge, Awareness, and Understanding of Pediatric Triage Among Nursing Officers in India: A Multicenter Study.

Triage is crucial in patient screening within emergency departments (EDs) worldwide. It is one of the essential and standard medical practices in many developed countries. However, in India, there is a need for improvement in triage utilization, as it is predominantly performed by resident doctors or medical officers, leading to an uneven distribution of clinical skills among healthcare providers (HCPs). A comprehensive analysis incorporating literature review and data collection revealed that while mandatory screening is conducted in most Indian EDs, the formal implementation of standardized triage protocols remains limited. Like in developed countries, registered nurses or nursing officers (NOs) can be effectively trained and directed to play the role of dedicated triage personnel in EDs of most of the healthcare facilities in India. This study aimed to examine the current state of triage utilization and its impact on the distribution of responsibilities among HCPs in Indian EDs. Through this online survey, the investigatorsassessed the knowledge and practical understanding of clinical triaging among NOs, working at various hospitals nationwide. The participants included 5,029 NOs working in various parts of India, predominantly nursing graduates (82.52%), the majority being employed in government healthcare settings (84.01%)and most having over five years of cumulative working experience in the ED (70.77%). Nurses showed inadequate knowledge and awareness about the Pediatric Assessment Triangle (PAT) used for quick initial evaluation (62.18%amongall participants). Concerning the complete triage process applicable, especially in pediatric ED settings, they had even less satisfactory knowledge and understanding, e.g., identifying primary (28.27%) and secondary (22.69%) survey components via focused history and examination, properly using temperature assessment (23.32%) and instant blood glucose level assessment (22.95%) in triage, and knowing various types of internationally accepted triage systems for ED-based health facilities such as the Emergency Severity Index (ESI), Canadian Triage and Acuity Scale (CTAS), and Australasian Triage Scale (ATS) (15.87%). ANOVA and post hoc analysis revealed that the intergroup performance of the study participants with maximum correct responses to the knowledge-determining specified subset of the questionnaire depicts the significantly higher role of graduate nursing degree over diploma such as General Nursing and Midwifery (GNM)/Auxiliary Nursing and Midwifery (ANM) qualification, working in government hospital versus private setup, and ED working experience of >5 years over that of <5 years. Of the participants in the study, 50% were not evaluated for cognitive or psychomotor domains during their assessment examinations. The research illuminated a significant disparity in knowledge and proficiency levels among Indian nurses concerning pediatric triage, especially with the ability to effectively apply the PAT for initial patient evaluations, discern components of primary and secondary surveys, and comprehend various triage systems. This study underscores the importance of comprehensive reform in the Indian healthcare system and teaching curriculum by emphasizing clinical triage training and interprofessional collaboration, and establishing guidelines and regulations to ensure consistent and standardized triage practices across all EDs.

The hospital care and outcomes of long-term care patients treated by paramedics during an emergency call: exploring the potential impact of 'treat-and-refer' pathways and community paramedicine.

Adults living in long-term care (LTC) are at increased risk of harm when transferred to the emergency department (ED), and programs targeting treatment on-site are increasing. We examined characteristics, clinical course, and disposition of LTC patients transported to the ED to examine the potential impact of alternative models of paramedic care for LTC patients. We conducted a health records review of paramedic and ED records between April 1, 2016, and March 31, 2017. We included emergency calls originating from LTC centers and patients transported to either ED campus of The Ottawa Hospital. We excluded scheduled or deferrable transfers, and patients with Canadian Triage and Acuity Scale of 1. We categorized patients into groups based on care they received in the ED. We calculated standardized differences to examine differences between groups. We identified four groups: (1) patients requiring no treatment or diagnostics in the ED (7.9%); (2) patients receiving ED treatment within current paramedic directives and no diagnostics (3.2%); (3) patients requiring diagnostics or ED care outside current paramedic directives (54.9%); and (4) patients requiring admission (34.1%). This study found 7.9% of LTC patients transported to the ED did not receive diagnostics, medications, or treatment, and overall 11.1% of patients could have been treated by paramedics within current medical directives using 'treat-and-refer' pathways. This group could potentially expand utilizing community paramedics with expanded scopes of practice.

Effect of a High-Sensitivity Troponin I and Associated Diagnostic Protocol on Emergency Department Length of Stay: A Retrospective Cohort Study

BackgroundThe objective of this study was to assess the introduction of a high-sensitivity troponin I (hs-TnI) assay and its associated accelerated protocol on emergency department (ED) length of stay (LOS) for patients presenting with chest pain, compared to an accelerated diagnostic protocol using conventional troponin (TnI) testing. MethodsWe conducted a retrospective cohort study of all adults with a primary presenting complaint of chest pain of cardiac origin and a Canadian Triage and Acuity Scale score of 2 or 3, between November 8, 2019 and November 9, 2021, to a tertiary-care urban Canadian ED. The primary outcome was ED LOS. Secondary outcomes included consultation proportions and major adverse cardiac events within 30 days of the index ED visit. ResultsA total of 2640 patients presenting with chest pain were included, with 1333 in the TnI group and 1307 in the hs-TnI group. Median ED LOS decreased significantly, from 392 minutes for the TnI group, and 371 minutes for the hs-TnI group (median difference = 21 minutes; 95% confidence interval: 5.3, 36.7). The numbers of consultations and admissions were not statistically different between study periods. The major adverse cardiac events outcomes did not change following the implementation of the hs-TnI test (13.6% vs 13.1%; P = 0.71). ConclusionsThe implementation of an accelerated chest pain protocol using an hs-TnI assay in a tertiary-care Canadian ED was associated with a modest reduction of LOS for all patients, and a substantial reduction of LOS for patients undergoing serial troponin testing. This strategy was safe, with no increase in adverse outcomes.

The Prevalence and Utilization of Prehospital IV Access in Critically Ill Patients in the Emergency Department.

Despite the pivotality of emergency medical services (EMS) in prehospital care for patient stabilization, prehospital intravenous(IV) access, a standard practice, remains an ambiguity in Saudi Arabia in terms of its prevalence of placement, justification, and utilization. In this study, we aim to estimate the prevalence and utilization rate of prehospital IV access placement in patients transported to King Khalid University Hospital (KKUH)Emergency Medicine Department in Riyadh by EMS and determine the relationship between the prevalence and utilization rate of prehospital IV access in Canadian Triage and Acuity Scale (CTAS) levels 1 and 2in trauma and non-trauma patients. This observational cross-sectional study was conducted over six months. A total of 181 cases of CTASlevels 1 and 2 adult patients were included. Data were collected by trained nurses using convenient sampling through an author-developed questionnaire. The prevalence of prehospital IV line placement was 28.7%, with a utilization rate of 50%, and was notably higher among CTAS level 1 cases (69.2%). Additionally, trauma cases had a higher prevalence of prehospital IV access (53.5%) compared to medical cases (odds ratio (OR): 4.73, 95% confidence interval (CI): 4.73, 4.73, p<0.05). Among patients with prehospital IV lines, the majority (92.3%) were patent and functional. Upon arrival, 73.1% of patients had their prehospital IV line replaced, with hospital protocol being the most common reason for the replacement (73.7%). A minority of the patients had prehospital vascular access, and of those, half remained unused. Trauma cases and CTAS level 1 patients had a higher prevalence and utilization of prehospital IV access. Furthermore, trauma cases were more associated with prehospital IV access establishment and utilization.

Assessing the reliability of pediatric emergency medicine billing code assignment for future consideration as a proxy workload measure.

Prediction of pediatric emergency department (PED) workload can allow for optimized allocation of resources to improve patient care and reduce physician burnout. A measure of PED workload is thus required, but to date no variable has been consistently used or could be validated against for this purpose. Billing codes, a variable assigned by physicians to reflect the complexity of medical decision making, have the potential to be a proxy measure of PED workload but must be assessed for reliability. In this study, we investigated how reliably billing codes are assigned by PED physicians, and factors that affect the inter-rater reliability of billing code assignment. A retrospective cross-sectional study was completed to determine the reliability of billing code assigned by physicians (n = 150) at a quaternary-level PED between January 2018 and December 2018. Clinical visit information was extracted from health records and presented to a billing auditor, who independently assigned a billing code-considered as the criterion standard. Inter-rater reliability was calculated to assess agreement between the physician-assigned versus billing auditor-assigned billing codes. Unadjusted and adjusted logistic regression models were used to assess the association between covariables of interest and inter-rater reliability. Overall, we found substantial inter-rater reliability (AC2 0.72 [95% CI 0.64-0.8]) between the billing codes assigned by physicians compared to those assigned by the billing auditor. Adjusted logistic regression models controlling for Pediatric Canadian Triage and Acuity scores, disposition, and time of day suggest that clinical trainee involvement is significantly associated with increased inter-rater reliability. Our work identified that there is substantial agreement between PED physician and a billing auditor assigned billing codes, and thus are reliably assigned by PED physicians. This is a crucial step in validating billing codes as a potential proxy measure of pediatric emergency physician workload.

Prehospital prediction of hospital admission for emergent acuity patients transported by paramedics: A population-based cohort study using machine learning.

The closest emergency department (ED) may not always be the optimal hospital for certain stable high acuity patients if further distanced ED's can provide specialized care or are less overcrowded. Machine learning (ML) predictions may support paramedic decision-making to transport a subgroup of emergent patients to a more suitable, albeit more distanced, ED if hospital admission is unlikely. We examined whether characteristics known to paramedics in the prehospital setting were predictive of hospital admission in emergent acuity patients. We conducted a population-level cohort study using four ML algorithms to analyze ED visits of the National Ambulatory Care Reporting System from January 1, 2018 to December 31, 2019 in Ontario, Canada. We included all adult patients (≥18 years) transported to the ED by paramedics with an emergent Canadian Triage Acuity Scale score. We included eight characteristic classes as model predictors that are recorded at ED triage. All ML algorithms were trained and assessed using 10-fold cross-validation to predict hospital admission from the ED. Predictive model performance was determined using the area under curve (AUC) with 95% confidence intervals and probabilistic accuracy using the Brier Scaled score. Variable importance scores were computed to determine the top 10 predictors of hospital admission. All machine learning algorithms demonstrated acceptable accuracy in predicting hospital admission (AUC 0.77-0.78, Brier Scaled 0.22-0.24). The characteristics most predictive of admission were age between 65 to 105 years, referral source from a residential care facility, presenting with a respiratory complaint, and receiving home care. Hospital admission was accurately predicted based on patient characteristics known prehospital to paramedics prior to arrival. Our results support consideration of policy modification to permit certain emergent acuity patients to be transported to a further distanced ED. Additionally, this study demonstrates the utility of ML in paramedic and prehospital research.

Machine learning to identify attributes that predict patients who leave without being seen in a pediatric emergency department.

To characterize patients who left without being seen (LWBS) from a Canadian pediatric Emergency Department (ED) and create predictive models using machine learning to identify key attributes associated with LWBS. We analyzed administrative ED data from April 1, 2017, to March 31, 2020, from IWK Health ED in Halifax, NS. Variables included: visit disposition; Canadian Triage Acuity Scale (CTAS); triage month, week, day, hour, minute, and day of the week; sex; age; postal code; access to primary care provider; visit payor; referral source; arrival by ambulance; main problem (ICD10); length of stay in minutes; driving distance in minutes; and ED patient load. The data were randomly divided into training (80%) and test datasets (20%). Five supervised machine learning binary classification algorithms were implemented to train models to predict LWBS patients. We balanced the dataset using Synthetic Minority Oversampling Technique (SMOTE) and used grid search for hyperparameter tuning of our models. Model evaluation was made using sensitivity and recall on the test dataset. The dataset included 101,266 ED visits where 2009 (2%) records were excluded and 5800 LWBS (5.7%). The highest-performing machine learning model with 16 patient attributes was XGBoost which was able to identify LWBS patients with 95% recall and 87% sensitivity. The most influential attributes in this model were ED patient load, triage hour, driving minutes from home address to ED, length of stay (minutes since triage), and age. Our analysis showed that machine learning models can be used on administrative data to predict patients who LWBS in a Canadian pediatric ED. From 16 variables, we identified the five most influential model attributes. System-level interventions to improve patient flow have shown promise for reducing LWBS in some centres. Predicting patients likely to LWBS raises the possibility of individual patient-level interventions to mitigate LWBS.

Management of fever and acute painful crises in children with sickle cell disease in emergency departments: a tertiary hospital experience.

Sickle Cell Disease (SCD) is highly prevalent in Saudi Arabia with variable demographics and access to health care facilities including emergency departments. Literature reviews for locally published articles are deficient in the in-depth evaluation of current emergency practices in managing patients with SCD. The study aims to assess the current emergency practice in managing SCD patients in tertiary hospitals. We reviewed data of 212 visits by patients with SCD over three years and assessed the current emergency department practices in managing common SCD crises, such as vaso-occlusive (VOC) and febrile episodes. Our findings revealed that 47.2%, 37.7%, and 15% of the patients presented with pain, fever, or both, respectively. The patients were triaged level III according to the Canadian triage and acuity scale system in 89% of the visits. The Median time for patients to see healthcare providers was 22 min. In the first 2 h, 86% of the patients received at least one fluid bolus and 79% of them received appropriate analgesia for pain crises. Approximately 41.5% of the patients with fever were admitted and received ceftriaxone as single intravenous antimicrobial agent. However, none of the patients had bacteremia. Only 2.4% of the patients had either urinary tract infection or osteomyelitis based on imaging. ED management is a key factor in the successful management of patients with SCD in a timely manner by providing fluids, analgesia, and antibiotics. Adopting evidence-based guidelines and avoiding unnecessary admissions are suggested in clinically well patients with fever in the era of completed vaccination, antibiotic prophylaxis, and good access to care for patients with a clear viral infection focus.

Comparison between local and three validated triage systems in an emergency department for 2126 children under 3 months.

Triage of patients less than 3 months old was not already studied. The aim was to evaluate Paediatric Emergency Department triage in patients less than 3 months old and newborns using a local system in comparison with three validated paediatric triage systems (Canadian Triage and Acuity Scale, Manchester Triage System and Emergency Severity Index) and to determine inter-system agreement. All admissions of patients less than 3 months old admitted to the Emergency Department of the Saint Vincent University Hospital between April 2018 and December 2019 were included. The local triage system level was determined prospectively for comparison with retrospectively calculated triage levels of the validated systems. Hospitalisation rates were compared and inter-system agreements determined. Among emergency admissions, 2126 were included (55% males, mean age 45 days). Hospitalisation rate increased with priority severity as determined by all triage systems studied. Cohen's kappa showed slight agreement between the local triage system and the Canadian Triage and Acuity Scale, Emergency Severity Index and Manchester Triage System (weighted kappa = 0.133, 0.185 and 0.157 respectively). Whether prospective or retrospective triage used, the systems studied exhibited good association with hospitalisation rate for patients aged less than 3 months and newborn infants.

Economic evaluation of tele-resuscitation intervention on emergency department pediatric visits in the Niagara Region, Canada a pilot study.

The use of telemedicine in critical care is emerging, however, there is a paucity of information surrounding the costs relative to health gains in the pediatric population. This study aimed to estimate the cost-effectiveness of a pediatric tele-resuscitation (Peds-TECH) intervention compared to the usual care in five community hospital emergency departments (EDs). Using a decision tree analysis approach with secondary retrospective data from a 3-year time period, this cost-effectiveness analysis was completed. A mixed methods quasi-experimental design was embedded in the economic evaluation of Peds-TECH intervention. Patients aged <18 years triaged as Canadian Triage and Acuity Scale 1 or 2 at EDs were eligible to receive the intervention. Qualitative interviews were conducted with parents/caregivers to explore the out-of-pocket (OOP) expenses. Patient-level health resource utilization was extracted from Niagara Health databases. The Peds-TECH budget calculated one-time technology and operational costs per patient. Base-case analyses determined the incremental cost per year of life lost (YLL) averted, and additional sensitivity analysis confirmed the robustness of the results. Odds ratio for mortality among cases was 0.498 (95% CI: 0.173, 1.43). The average cost of a patient receiving the Peds-TECH intervention was $2,032.73 compared to $317.45 in usual care. In total, 54 patients received the Peds-TECH intervention. Fewer children died in the intervention group resulting in 4.71 YLL. The probabilistic analysis revealed an incremental cost-effectiveness ratio of $64.61 per YLL averted. Peds-TECH appears to be a cost-effective intervention for resuscitating infants/children in hospital emergency departments.

B.2 Short-term outcome in simultaneous acute code stroke activations in the emergency department

Background: We aim to assess the effect of simultaneous acute code stroke activation(ACSA) in patients undergoing reperfusion therapies in the emergency department on home time at 90 days. Methods: We assessed ACSA over 20 months from the QuICR(Quality Improvement and Clinical Research Alberta Stroke Program) Registry. We defined Simultaneous reperfusion therapy as, ACSA within 60 min of the arrival of any patient receiving intravenous thrombolysis or ACSA within 150 min of the arrival of any patient receiving endovascular thrombectomy (based on the Canadian Triage and Acuity Scale, average local door-to-needle and door-to-puncture times)Results: A total of 2607 ACSA occurred at a mean±SD of 130.8±17.1 per month during the study period. 545 (20.9%) underwent acute reperfusion therapy with a mean age of 70.6±14.2 years, 45.9%(n=254) were female and a median (IQR) NIHSS of 13(8-18). Simultaneous reperfusion therapies occurred in 189(34.6%). There was no difference in the median door-to-CT time between the simultaneous (16, 11-23 min) and non-simultaneous (15, 11–21 min, p=0.3) activations. There was no difference in the median home time at 90 days between the two groups. Conclusions: Simultaneous ACSA occurs in one-third of patients receiving acute reperfusion therapies. An optimal workflow may help mitigate the clinical and system burden associated with simultaneity.

Edmonton Zone triage project (EZ Triage)

Background: Canadian Emergency Departments (ED) use the five-point Canadian Triage Acuity Scale (CTAS) to prioritize patients according to acuity. CTAS scores are used to make decisions on patient flow, staffing complement, and funding. Variations in triage can lead to mis-categorization and delayed care for critically ill patients. Edmonton zone quality improvement audits reduced high and low-risk vital sign errors (86% and 78%, respectively), increased between-nurse triage consistency, and levelled triage burden for individual nurses. However, previous audits were time-consuming and required auditors with clinical, data management, and analysis expertise, preventing their wide-scale adoption.&#x0D; &#x0D; Implementation: This project utilizes the AHS AIW implementation framework. It is the extension of a triage audit and feedback tool that was developed and validated over a three-year window (Cotton et al., 2021). This current project is a scaling-up of the QI audit framework to a Tableau dashboard that will allow ED administrators and educators to efficiently examine individual nurse-level and department triage variation to craft local QI measures to improve triage accuracy.&#x0D; &#x0D; The newly developed QI tool uses raw EPIC data retrieved from AHS data warehouses. It translates the framework to a python script that duplicates existing Excel QI framework Boolean logic and generates binary output variables. These variables are then loaded into a preformatted Tableau dashboard that displays both department and nurse-level triage variances (trimmed mean and standard deviation) for the following variables: high and low acuity vital sign error rates, triage acuity overrides, and sepsis alerts. The dashboard data (and visualizations) allow users to filter errors by nurse and error type. They include all the relevant triage-associated data and can be used for near real-time monitoring of triage variances or downloaded for additional department-level analyses.&#x0D; &#x0D; Patient and Family Engagement: Triage has consistently been identified as an area of concern for hospital administrators, clinicians, and patients. Most complaints received by hospitals about ED care are generated at triage. Literature has suggested that triage can be cognitively demanding for nurses, and data have suggested that patients have experienced bias during triage. This project will benefit patients by minimizing errors, ensuring consistent triage, and allowing other sites across the province to engage in similar QI efforts. Because these triage QI efforts require the review of patient-sensitive data, patients were not included in the analyses. &#x0D; &#x0D; Evaluation Methods: The output of the triage audit dashboard was assessed in two ways: by soliciting the feedback of clinical audit end-users on the ease of use and operability of the dashboard, and by assessing the reliability of the tool by comparing it to the existing definitions and standard of screening.&#x0D; &#x0D; The user interface of the triage audit system was assessed and refined soliciting feedback from end-users of the system. Each refinement cycle was accompanied by further feedback. A random 10,000-patient sample was used to perform assess the performance of the tool. The reliability of the dashboard was calculated by the sensitivity, specificity, accuracy, and agreement of expert raters. Between-group comparisons of expert and automated systems to gold-standard manual reviews were performed using Cohen’s Kappa.&#x0D; &#x0D; Results: Feedback was collected from two emergency departments. Refinement cycles resulted in a dashboard that allows decision-makers to compare practice at a nursing level while offering near-real-time feedback and access to patient visit-level data. Feedback resulted in the addition of Systemic Inflammatory Response Syndrome (SIRS) related errors to the model. There were 10,000 patient visits considered for analysis. Patients less than 18 years of age (3%, n=306 visits) and visits with incomplete data (n=86) were removed. The final sample was 9608 visits.&#x0D; &#x0D; Four categories of error were assessed: High-acuity, low-acuity, pain, and SIRS-criteria. Automated screening of high and low acuity errors had 100% sensitivity, specificity, and accuracy (κ =1, p&lt;0.001) and outperformed expert review for high-risk (sensitive=97.8%, specificity=100%, accuracy=99.98%; κ =0.989, p,0.001) and low-risk errors (sensitivity=98.9%, specificity=100%, accuracy=99.98%; κ =0.994, p,0.001) compared to gold-standard expert manual review. Computer screening outperformed (sensitivity=71.3%, specificity=96.7%, accuracy=96.27%; κ =0.39, p,0.001) compared to expert assessment for pain errors (sensitivity=52.0%, specificity=97.4%, accuracy=96.58%; κ =0.335, p&lt;0.001). Expert screening (sensitivity=100%, specificity=99.9%, accuracy=99.9%; κ =0.962, p&lt;0.001); outperformed computer screening (sensitivity=7.9%, specificity=100%, accuracy=98.91%; κ =0.145, p&lt;0.001) for SIRS-related errors. &#x0D; &#x0D; Advice and Lessons Learned:&#x0D; &#x0D; Maintaining data integrity for the dashboard required multiple rounds of feedback and clinician input.&#x0D; Because of the small sample and subsequent exclusion of pediatric patients the current dashboard and error detections thresholds levels for pediatric vital sign modifiers will need further validation before being used for pediatric ED patients.&#x0D; Further refinements to the tool are needed to incorporate previously used text-parsing algorithms into the detection of pain-related triage errors.&#x0D;

Workflow in Simultaneous acute code Stroke activations in the emergency department (P6-5.021)

<h3>Objective:</h3> To assess the effect of simultaneous acute code stroke activation (ACSA) in the emergency department on the door-to-needle (DTN) time of patients with acute ischemic stroke eligible for reperfusion therapies. <h3>Background:</h3> Simultaneous emergency call activations carry increased workload that could possibly compromise quality parameters and patient outcomes. <h3>Design/Methods:</h3> All ACSA from March 2021 to August 2022 from the QuICR (Quality Improvement and Clinical Research Alberta Stroke Program) Registry were assessed. We defined Simultaneity based on the Canadian Triage and Acuity Scale, average local DTN and door-to-puncture (DTP) times: ACSA 30 min prior to any patient receiving intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT); ACSA within 60 min of any patient receiving IVT and ACSA within 120 min of any patient receiving EVT. The simultaneity grade 1 was 2 patients care overlap as per simultaneous ACSA definition, grade 2 was 3 patients care overlap and grade 3 was &gt;3 patients care overlap. Independent sample Kruskal-Wallis test was applied to assess the between-group differences in median treatment times. <h3>Results:</h3> 496 patients (20.9%, n=2364) underwent acute reperfusion therapy with a mean±SD age of 70.4±14.6 years, 45%(n=224) were female and a median (IQR) NIHSS of 12 (10) during the study period. Simultaneous ACSA was 163 (32.9%). The median (IQR) DTN time in the non-simultaneous group(n=205), grades 1 (n=76), 2 (n=13) and 3 (n=4) simultaneities was 38 (22)min, 39.5 (21)min, 45 (26)min, 58.5 (19.5)min respectively (p=0.27). The median (IQR) DTP time in the non-simultaneous group (n=187), in grades 1 (n=69), 2 (n=27) and 3 (n=6) simultaneities was 99 (42)min, 93 (48)min, 98 (39)min and 153 (112.75)min respectively (p=0.6). <h3>Conclusions:</h3> Simultaneous ACSA occurs in one-third of patients receiving reperfusion therapies. No differences were noted in treatment times between the study groups. Novel strategies are required to understand the effect of simultaneous ACSA on the acute stroke team and emergency department. <b>Disclosure:</b> Dr. Sarmiento has nothing to disclose. Miss Bhangoo has nothing to disclose. The institution of Dr. Jeerakathil has received research support from University Hospital Foundation. Dr. Shuaib has nothing to disclose. Dr. Buck has nothing to disclose. Ms. Taralson has nothing to disclose. Ms. Moniz has nothing to disclose. Dr. Kate has nothing to disclose.

Impact of Health Link utilization on emergency department visits.

Our aim was to compare Health Link utilization in urban and rural Alberta by metrics relevant to the ED. Data on Health Link callers from January 1, 2018-December 31, 2019 was extracted from the National Ambulatory Care Reporting System, including postal code, location of ED attended, Canadian Triage Acuity Scale (CTAS) assigned at ED, age, and self-identified gender. Usage density (presentations/100/year), patient demographics (age, self-identified gender), and ED metrics (CTAS, investigations, admission) were compared for Health Link ED referrals and direct ED visits. In this period, 900,196 individuals called Health Link, 241,103 were referred to the ED, 58% (140,614) of which presented to the ED within 24h of their call. These referrals constituted 3.4% of the total ED visit population (4,194,735). Looking at the density of ED utilization, this is greater in rural than urban settings with respect to patients who present directly to the ED (90.9 vs. 36.5 presentations/100/year). There is a sparser density of Health Link ED visits in rural settings than in urban centres (1.5 vs. 1.6). Urban ED presentations were more often triaged as a CTAS 1-3 than a CTAS 4-5 if they had presented after a Health Link referral (76.0% CTAS 1-3) than a direct ED visit (63.0% CTAS 1-3). This effect is greater for rural patients, who also more likely to present as a CTAS 1-3 than a CTAS 4-5 if they were referred through Health Link (61.1% CTAS 1-3) compared to those who directly went to the ED (39.0% CTAS 1-3). This study on Health Link describes how tele-health can often triage higher acuity patients to appropriately receive ED level care, which may be important for future development of health care and ED infrastructure.

Effect of the COVID-19 pandemic on emergency department utilization of computed tomography scans of appendicitis and diverticulitis

PurposeInvestigating the effect of the COVID-19 lockdown on adult patient visits, computed tomography (CT) abdominal scans, and presentations of appendicitis and diverticulitis, to emergency departments (ED) in St. John’s NL.MethodsA retrospective quantitative analysis was applied, using ED visits and Canadian Triage and Acuity Scale (CTAS) scores. mPower (Nuance Communications, UK) identified CT abdominal scan reports, which were categorized into (1) normal/other, (2) appendicitis, or (3) diverticulitis. Time intervals included pre-lockdown (January–February), lockdown (March–June), and post-lockdown (July–August). Data from 2018 to 2019 (January–August) were used to generate expected patient volumes for 2020, and pre- and post-lockdown were included to control for other variables outside the lockdown.ResultsChi-squared goodness of fit tested for deviations from predicted means for 2018–2019. Compared to expectations, daily ED visits from January to August 2020 showed a significant (p < 0.001) decrease in patient volumes independent of gender, age, and CTAS scores. During and post-lockdown, CT abdominal scans did not drop in proportion to patient volume. Appendicitis presentations remained indifferent to lockdown, while diverticulitis presentations appeared to wane, with no difference in combined complicated cases in comparison to what was expected.ConclusionDuring lockdown, significantly fewer patients presented to the ED. The proportion of ordered CT abdominal scans increased significantly per person seen, without change in CTAS scores. Considering combined pathology cases increased during the lockdown, ED physicians were warranted in increasing abdominal imaging as patients did not avoid the ED. This may have resulted from a change in clinical practice where the uncertainty of COVID-19 increased CT scan usage.

The COVID-19 impact and characterization on substance use-related emergency department visits for adolescents and young adults in Canada: Practical implications.

Coronavirus (COVID-19)-related stressors precipitated the mental health crisis and increased substance use in Canada and worldwide. As the pandemic continues to evolve, monitoring and updating substance use-related ED visit trends is essential to ensure the stability and quality of ED services under the prolonged pandemic timeline. This study examined the trends and characterization of substance use-related ED visits during the pandemic among adolescents and young adults (aged 13-25 years) in Ontario, Canada. Descriptive statistics and binary logistic regression analyses were conducted using population-based, repeated cross-sectional data. The volume, patient characteristics (age and sex) and hospital/ED visit features (triage to end time, timing of the visit, triage level and referral source) were compared before (2019) and during COVID-19 (2020 and 2021) by each substance type (alcohol, opioid, cannabis, sedatives, cocaine, stimulants and multiple psychoactive substances). Substance use-related ED visits decreased by 1.5 times during the pandemic compared to the prepandemic level. However, opioid-related ED visits continued to show an increasing trend and did not recover to the prepandemic level in 2021. Moreover, a significant increase in emergent/life-threatening triage levels (Canadian Triage and Acuity Scales 1 and 2) in substance-related ED visits is alarming (2019 = 36.8%, 2020 = 38.7% and 2021 = 38.4%). We also found a general decrease in weekend visits, overnight visits and visits on statutory holidays, and substance use-related ED patients tended to stay longer (over 6 h) in the ED during the pandemic. Our findings indicate unmet substance use treatment needs due to the limited accessibility and heightened threshold for ED visits during the pandemic. Providing access to substance treatment/programs outside ED is critical to reducing substance use-related complications presenting in the ED. Also, policies addressing the pandemic-related complexities in the ED and Health Human Resource challenges are warranted.

Validity of the Paediatric Canadian Triage Acuity Scale in a Tertiary Hospital: An Analysis of Severity Markers' Variability

With the increasing influx of patients and frequent overcrowding, the adoption of a valid triage system, capable of distinguishing patients who need urgent care, from those who can wait safely is paramount. Hence, the aim of this study is to evaluate the validity of the Paediatric Canadian Triage and Acuity Scale (PaedCTAS) in a Portuguese tertiary hospital. Furthermore, we aim to study the performance and appropriateness of the different surrogate severity markers to validate triage. This is a retrospective study considering all visits to the hospital’s Paediatric Emergency Department (PED) between 2014 and 2019. This study considers cut-offs on all triage levels for dichotomization in order to calculate validity measures e.g. sensitivity, specificity and likelihood ratios, ROC curves; using hospital admission, admission to intensive care and the use of resources as outcomes/markers of severity. Over the study period there were 0.2% visits triaged as Level 1, 5.7% as Level 2, 39.4% as Level 3, 50.5% as Level 4, 4.2% as Level 5, from a total of 452,815 PED visits. The area under ROC curve was 0.96, 0.71, 0.76, 0.78, 0.59 for the surrogate markers: “Admitted to intensive care”; “Admitted to intermediate care”; “Admitted to hospital”; “Investigations performed in the PED” and “Uses PED resources”, respectively. The association found between triage levels and the surrogate markers of severity suggests that the PedCTAS is highly valid. Different surrogate outcome markers convey different degrees of severity, hence different degrees of urgency. Therefore, the cut-offs to calculate validation measures and the thresholds of such measures should be chosen accordingly.