Urgent Category Research Articles

Recalibration of the delirium prediction model for ICU patients (PRE-DELIRIC): a multinational observational study

Recalibration and determining discriminative power, internationally, of the existing delirium prediction model (PRE-DELIRIC) for intensive care patients. A prospective multicenter cohort study was performed in eight intensive care units (ICUs) in six countries. The ten predictors (age, APACHE-II, urgent and admission category, infection, coma, sedation, morphine use, urea level, metabolic acidosis) were collected within 24 h after ICU admission. The confusion assessment method for the intensive care unit (CAM-ICU) was used to identify ICU delirium. CAM-ICU screening compliance and inter-rater reliability measurements were used to secure the quality of the data. A total of 2,852 adult ICU patients were screened of which 1,824 (64%) were eligible for the study. Main reasons for exclusion were length of stay <1 day (19.1%) and sustained coma (4.1%). CAM-ICU compliance was mean (SD) 82 ± 16% and inter-rater reliability 0.87 ± 0.17. The median delirium incidence was 22.5% (IQR 12.8-36.6%). Although the incidence of all ten predictors differed significantly between centers, the area under the receiver operating characteristic (AUROC) curve of the eight participating centers remained good: 0.77 (95% CI 0.74-0.79). The linear predictor and intercept of the prediction rule were adjusted and resulted in improved re-calibration of the PRE-DELIRIC model. In this multinational study, we recalibrated the PRE-DELIRIC model. Despite differences in the incidence of predictors between the centers in the different countries, the performance of the PRE-DELIRIC-model remained good. Following validation of the PRE-DELIRIC model, it may facilitate implementation of strategies to prevent delirium and aid improvements in delirium management of ICU patients.

Organ Donation and Transplantation in the UK—The Last Decade

Over the decade between 2003 and 2012, the UK has seen major changes in how organ donation and transplantation is delivered. The number of deceased organ donors has increased from 709 (12.0 per million population [pmp]) to 1,164 (18.3 pmp); this increase has been predominantly a result of an increase in donors after circulatory death (DCD) (from 1.1 pmp to 7.9 pmp) while the numbers of donors after brain death (DBD) has remained broadly stable (around 10.5 pmp). The donor population has become older (from 14% 60 years or over to 35%) and heavier (from 14% with body mass index >=30 kg/m2 to 23%). Despite these changes in demographic factors, the number of organs retrieved from DBD donors has risen from a mean of 3.6 to 4.0 per donor and for DCD donors from 2.2 to 2.6. The number of transplants in adults in 2012 was 2,709 (967 DBD, 708 DCD, and 1,034 living) for kidney alone, 246 pancreas (including 172 kidney and pancreas), 792 (611 DBD, 142 DCD, 36 living, and 3 domino) for liver, 136 for heart only, and 179 (145 DBD and 34 DCD) for lung only. Median waiting times to transplant for adult patients were 1,167, 339, 141, 293, and 311 days, respectively. The proportion of adult non-urgent registrants in 2009 (2007 for kidneys) who were removed from the waiting list or died awaiting a graft within 1 year was 3% for kidneys, 6% for pancreas, 19% for liver, 27% for heart, and 24% for lung. Outcomes after solid organ transplants are improving; for adult patients grafted between 2003 and 2005, 5-year graft survival for kidney is 84% (DBD), 87% (DCD), and 92% (living donor), for simultaneous kidney and pancreas 72%, and for pancreas alone 50% (DBD). Five-year patient survival for liver is 77% (DBD) and 68% (DCD), heart 67%, and lung 52% (DBD). Although rates of organ donation and transplantation have increased in the UK, this has been almost solely because of a rise in DCD donation. Although donor age and weight is increasing, graft survival has generally improved. Despite a recent fall in the number of patients on the transplant waiting list, there remains a significant gap between the need for transplantation and the number of organs available from deceased and living donors. The implementation of a new strategy following the recommendations of the Organ Donation Task Force in 2008 has had a major impact in bringing together clinicians involved in both organ donation and transplantation, and these changes and clinical enthusiasm have been instrumental in achieving success. With an emphasis on the need to increase the family consent rate for organ donation, which has failed to show any improvement over the last 5 years, a new UK strategy for organ donation and transplantation, introduced in 2013, will further increase organ transplantation in the UK.

A dynamic mathematical model of red blood cell clinical demand to assess the impact of prolonged blood shortages and transfusion restriction policies

Estimating change in clinical demand for red blood cells (RBCs) from a disaster, as well as triaging introduced in response, is essential to plan effectively for a major blood shortage. We aimed to develop a RBC demand model to assess the impact of restriction policies on RBC use and patient outcomes. A compartmental dynamic model was developed in which patients require RBCs acutely (within 1 hr), urgently (24 hr), semiurgently (1-7 days), or nonurgently; outcomes included death or remaining at or transitioning to more or less urgent categories. A mathematical model was developed with transitions governed by differential equations and calibrated to a baseline scenario of adequate blood supply (using population-based hospital data sets, registries, and RBC issues). Distribution into urgency categories was based on a prospective study of 5132 randomly selected RBC units. Scenarios when the blood supply is limited compared to baseline were investigated. Transition rates between urgency categories under these scenarios were established by clinician survey. In the baseline 21-day scenario, patients requiring the most RBCs were other surgery (2162, 22%), medical anemia (1916, 12%), malignant hematology (1092, 16%), and gastrointestinal hemorrhage (1115, 8%). A policy of withholding RBCs for all nonurgent indications results in an estimated reduction of only 1007 (11.2%) RBC units and, if extended to semiurgent, a reduction of 2567 (28.5%) RBC units. Based on this model, restrictions that withhold transfusion from nonurgent patients have minimal impact on RBC demand and may not be sufficient to address changed demand and/or decreased supply during a prolonged disaster.

OPTN/SRTR 2012 Annual Data Report: Heart

The number of heart transplants performed annually continues to increase gradually, and the number of adult candidates on the waiting list increased by 25% from 2004 to 2012. The heart transplant rate among active adult candidates peaked at 149 per 100 wait-list years in 2007 and has been declining since; in 2012, the rate was 93 heart transplants per 100 active wait-list years. Increased waiting times do not appear to be correlated with an overall increase in wait-list mortality. Since 2007, the proportion of patients on life support before transplant increased from 48.6% to 62.7% in 2012. Medical urgency categories have become less distinct, with most patients listed in higher urgency categories. Approximately 500 pediatric candidates are added to the waiting list each year; the number of transplants performed each year increased from 274 in 1998 to 372 in 2012. Graft survival in pediatric recipients continues to improve; 5-year graft survival for transplants performed in 2007 was 78.5%. Medicare paid for some or all of the care for nearly 40% of heart transplant recipients in 2010. Heart transplant appears to be more expensive than ventricular assist devices for managing end-stage heart failure, but is more effective and likely more cost-effective.

Accuracy of Triage for Children With Chronic Illness and Infectious Symptoms

This prospective observational study aimed to assess the validity of the Manchester Triage System (MTS) for children with chronic illnesses who presented to the emergency department (ED) with infectious symptoms. Children (<16 years old) presenting to the ED of a university hospital between 2008 and 2011 with dyspnea, diarrhea/vomiting, or fever were included. Chronic illness was classified on the basis of International Classification of Diseases, Ninth Revision, Clinical Modification, codes. The validity of the MTS was assessed by comparing the urgency categories of the MTS with an independent reference standard on the basis of abnormal vital signs, life-threatening working diagnosis, resource utilization, and follow-up. Overtriage, undertriage, and correct triage were calculated for children with and without a chronic illness. The performance was assessed by sensitivity, specificity, and diagnostic odds ratios, which were calculated by dichotomizing the MTS into high and low urgency. Of the 8592 children who presented to the ED with infectious symptoms, 2960 (35%) had a chronic illness. Undertriage occurred in 16% of children with chronic illnesses and in 11% of children without chronic illnesses (P < .001). Sensitivity of the MTS for children with chronic illnesses was 58% (95% confidence interval [CI]: 53%-62%) and was 74% (95% CI: 70%-78%) for children without chronic illnesses. There was no difference in specificity between the 2 groups. The diagnostic odds ratios for children with and without chronic illnesses were 4.8 (95% CI: 3.9-5.9) and 8.7 (95% CI: 7.1-11), respectively. In children presenting with infectious symptoms, the performance of the MTS was lower for children with chronic illnesses than for children without chronic illnesses. Nurses should be particularly aware of undertriage in children with chronic illnesses.

Assessment of interdisciplinary communication for Category 1 caesarean sections

We assessed how often the urgency of Category 1 caesarean sections was incorrectly recorded by the anaesthetic and theatre teams. Category 1 caesarean sections were identified over a 15-month period (September 2010 to November 2011), from the daily audit of emergency caesarean sections undertaken by the obstetric team. The categories of urgency as recorded by the attending anaesthetist and theatre team were noted for each case. There were 236 Category 1 caesarean sections identified, of which 47 were incorrectly recorded as Category 2 by either the anaesthetist alone (34), the theatre team alone (1) or both (12). Where the category of urgency was correctly recorded, 11.6% of cases had a decision-to-delivery interval of more than 30 min compared with 27.7% of cases recorded as Category 2 (p = 0.01, Fisher's exact test).

Impact du contenu du courrier médical sur la qualité du triage initial des patients adultes admis aux urgences

We conducted a two-month prospective study (8,171 admissions) in the Angers university hospital emergency room to analyse the impact of the referral letter on the initial triage of patients admitted to the emergency room performed by the reception and triage nurse.We analysed the level of priority of the CIMU triage scale (nurse's classification of emergency room patients), the presenting complaint, and the need for an urgent procedure before and after reading the referral letter and examined the nurse's comments for explanations concerning any triage changes.1,516 patients arriving with a referral letter (18.5% of admissions) were included and interpretable data were available for 756 of these cases. After reading the referral letter, nurses modified the CIMU triage level for 34 (4.5%) patients, the presenting complaint for 50 (6.6%) patients and eliminated the need for an urgent procedure for 70 (9.3%) patients. No significant difference was observed concerning the choice of the CIMU triage level (p = 0.908). However, changes in triage level were significantly more frequently towards a more urgent category (p = 0.005). Analysis of the nurse's comments showed that these results can be explained by the signs of severity indicated in the referral letter. Certain histories and/or diagnostic hypotheses appeared to lead nurses to eliminate the need for an urgent procedure.In this study, the referring physician's letter had a limited impact on the choice of triage level defined by the nurse on admission to the emergency room except for patients in whom the referral letter mentioned signs of severity, not observed at reception, led the nurse to apply a more urgent triage level. It would be interesting to study the information contained in the referral letter, useful for triage of patients admitted to the emergency room, in order to improve the impact of the referral letter on the quality of triage.

From decision to delivery - how fast we are with anaesthesia in different urgency categories for caesarean section

From decision to delivery - how fast we are with anaesthesia in different urgency categories for caesarean section

7.0 Obstetric management

7.0 Obstetric management

Mode of anaesthetic for category 1 caesarean sections and neonatal outcomes

Birth by emergency caesarean section (CS) is common and often considered urgent (category 1). In the UK, over half of all category 1 CS are performed under general anaesthesia (GA). In this setting, little is known about the effect of the mode of anaesthesia on the neonate. A retrospective cohort study was performed using routinely collected de-identified data from Mater Health Services, Brisbane, Australia. The data set included 533 term babies born by category 1 CS for presumed fetal compromise between 2008 and 2011. Bivariate and multivariate analyses were undertaken. The outcomes of 81 babies born by GA CS were compared with 452 by CS under regional anaesthesia (RA). Compared with a category 1 CS under RA, the decision-to-delivery interval for a GA CS was almost eight minutes faster (24.7 vs 32.6 minutes; P < 0.001). When adjusted for confounders, babies born by category 1 GA CS were significantly more likely to have an Apgar score < 7 at five minutes (aOR 6.89; 95%CI 1.79-26.55; P = 0.005), to require Neopuff or bag/mask ventilation for > 60 seconds (aOR 2.34; 95%CI 1.13-4.84; P = 0.022) and to be admitted to a neonatal intensive care nursery (aOR 2.24; 95%CI 1.16-4.31; P = 0.016). General anaesthesia was associated with short-term neonatal morbidity of term babies born by category 1 CS for presumed fetal compromise, despite enabling a more rapid delivery of the baby. These data should help inform the discussion between anaesthetist and obstetrician, in balancing the risks and benefits of the mode of anaesthesia.

Su1334 Does Urgency Categorisation (Triaging) Prevent Delayed Diagnoses and Treatment of Significant Gastric and Colonic Disease?

In a health care setting with waiting lists, urgency categories are frequently used to allocate clinical resources to patients in need. This practice is based upon the assumption that categorisation of patients would allow identification of those who require urgent treatment and those who may not be exposed to unacceptable risks if the treatment is deferred. Categorisation was done according to QLD health standards by consultants and includes three urgency categories: Cat 1 where patients should be seen within 30 days, Cat 2 to be seen within 90 days, and Cat 3 to be seen within 365 days.

Patients Who Leave Without Being Seen in Emergency Departments: An Analysis of Predictive Factors and Outcomes

The objective was to identify predictive factors and outcomes associated with patients who leave emergency departments (EDs) without being seen in Victoria, Australia. This was a retrospective observational study of Victorian ED patient visits between July 1, 2000, and June 30, 2005, using linked hospital, ED, and death registration data. Index ED visits were identified for patients who left without being seen (LWBS) and for those who completed ED treatment and were discharged home. Statistical analyses included a general description and univariate analysis of patient, ED visit, temporal, and hospital-level factors. Logistic regression models were developed to assess risk factors associated with LWBS status compared to patients who completed treatment, to assess 48 hour re-presentations to ED; 48-hour hospital admissions; and 2-,7-, and 30-day mortality among those who LWBS compared to those who completed treatment. Adjusted odds ratios (ORs) and 99% confidence intervals (CIs) are presented. There were 239,305 LWBS episodes, for 205,500 patients over the 5-year period. Independent factors associated with LWBS patients in comparison to those who completed treatment include patients who are younger (15 to 24 years, OR = 2.46, 99% CI = 2.37 to 2.56), male (OR = 1.07, 99% CI = 1.05 to 1.08), of Australian indigenous background (OR = 1.63, 99% CI = 1.53 to 1.73), of non-English-speaking background (OR = 1.08, 99% CI = 1.06 to 1.10), noncompensable status (OR = 1.73, 99% CI = 1.68 to 1.79), self-referring (OR = 1.46, 99% CI = 1.43 to 1.49), nonassisted arrival mode (OR = 1.35, 99% CI = 1.30 to 1.40), and those with a hospital admission in the 12 months before the ED presentation (OR = 1.53, 99% CI = 1.51 to 1.55). Patients who LWBS had triage categories of lower urgency (nonurgent, OR = 8.21, 99% CI = 8.00 to 8.43), attended during the evening (OR = 1.10, 99% CI = 1.08 to 1.12), on either Sunday (OR = 1.20, 99% CI = 1.18 to 1.23) or Monday (OR = 1.20, 99% CI = 1.17 to 1.23), in winter (OR = 1.14, 99% CI = 1.12 to 1.16), with higher rates occurring in higher volume EDs (OR = 2.20, 99% CI = 2.15 to 2.26). There was no greater risk of mortality for LWBS patients compared to patients who completed treatment. The risk of hospital admission within 48 hours of discharge was lower for LWBS patients (OR = 0.60, 99% CI = 0.58 to 0.62); however, ED re-presentation risk was higher (OR = 1.63, 99% CI = 1.60 to 1.67). Patients who leave EDs in Victoria, Australia, without being seen are at lower risk of hospital admission and at no greater risk of mortality, but are at higher risk of re-presenting to an ED compared to patients who complete treatment and are discharged home.

Reliability and validity of an Italian four-level emergency triage system

The goal of this study is to assess the reliability and validity of a four-level emergency triage system (Urgency Category (UC) 1 = immediate response; UC 2, 3 and 4 assessment within 20, 60 and 120 minutes respectively) used in an Italian large urban hospital with 60,000 emergency department (ED) visits annually.

Self-Referral and Serious Illness in Children With Fever

The goal of this study was to evaluate parents' capability to assess their febrile child's severity of illness and decision to present to the emergency department. We compared children referred by a general practitioner (GP) with those self-referred on the basis of illness-severity markers. This was a cross-sectional observational study conducted at the emergency departments of a university and a teaching hospital. GP-referred or self-referred children with fever (aged <16 years) who presented to the emergency department (2006-2008) were included. Markers for severity of illness were urgency according to the Manchester Triage System, diagnostic interventions, therapeutic interventions, and follow-up. Associations between markers and referral type were assessed by using logistic regression analysis. Subgroup analyses were performed for patients with the most common presenting problems that accompanied the fever (ie, dyspnea, gastrointestinal complaints, neurologic symptoms, fever without specific symptoms). Thirty-eight percent of 4609 children were referred by their GP and 62% were self-referred. GP-referred children were classified as high urgency (immediate/very urgent categories) in 46% of the cases and self-referrals in 45%. Forty-three percent of GP referrals versus 27% of self-referrals needed extensive diagnostic intervention, intravenous medication/aerosol treatment, hospitalization, or a combination of these (odds ratio: 2.0 [95% confidence interval: 1.75-2.27]). In all subgroups, high urgency was not associated with referral type. GP-referred and self-referred children with dyspnea had similar frequencies of illness-severity markers. Although febrile self-referred children were less severely ill than GP-referred children, many parents properly judged and acted on the severity of their child's illness. To avoid delayed or missed diagnoses, recommendations regarding interventions that would discourage self-referral to the emergency department should be reconsidered.

Effect of Triage on Waiting Time for Community Rehabilitation: A Prospective Cohort Study

Harding KE, Taylor NF, Leggat SG, Stafford M. Effect of triage on waiting time for community rehabilitation: a prospective cohort study. ObjectiveTo investigate how the allocation of referrals for a community rehabilitation service to triage categories affects waiting time from referral to first appointment, and whether other factors also contribute to variance in waiting time. DesignA prospective cohort study. SettingA multidisciplinary outpatient community rehabilitation program within a large metropolitan health service. ParticipantsConsecutive adult patients (N=379) commencing rehabilitation over a 3-month period. InterventionAllocation of referrals to a triage category of 1 (most urgent) to 4 (least urgent) by allied health clinicians guided by a written protocol. Main Outcome MeasureThe primary outcome was waiting time from referral to service commencement. ResultsThe small group of patients (4%) allocated to the most urgent category had significantly shorter mean waiting times than the other 3 categories (mean, 4.8d vs 19.6, 26.6, and 19.4d for categories 2, 3, and 4, respectively). Regression analysis indicated that approximately 11% of the variance in waiting time was accounted for by the triage categories. Site of treatment (home or center) and diagnosis also made small contributions (4% combined) to variance in waiting time. ConclusionsThe triage process ensured rapid service for a small number of urgent referrals, but made little difference to the waiting time of the vast majority of patients. Given the resources required for triaging patients, the results of this study lead us to question the value of the triage system in this setting.

Breast clinic triage tool: Telephone assessment of new referrals

Efficient systems to triage increasing numbers of new referrals to breast clinics are needed, to optimise the management of patients with cancer and benign disease. A tool was developed to triage the urgency of referrals and allocate the most appropriate clinician consultation (surgeon or breast physician (BP)).259 consecutive new referrals were triaged using the tool. 100% new cancers and 256 (98.8%) referrals overall were triaged to both appropriate category of urgency and the appropriate clinician.This triage tool provides a simple method for assessing new referrals to a breast clinic and can be easily delivered by trained administrative staff by telephone.

Solifenacin may improve sleep quality in patients with overactive bladder and sleep disturbance

Objective To examine the effect of solifenacin for not only overactive bladder symptoms but also sleep disturbance. Nocturia and urgency are independent factors for sleep disturbance. Methods Fifteen male patients with overactive bladder symptoms and sleep disturbance were enrolled in this study. The overactive bladder symptoms score (OABSS) and Athens insomnia scale (AIS) were used as a subjective questionnaire for overactive bladder symptoms and insomnia. The Actiwatch-16 (Mini-Mitter-Respironics, Inc., Bend, OR) was used as an objective measurement tool for insomnia. Total sleep time, sleep efficiency, sleep latency, wake-after-sleep onset, and number of awakenings were measured by the Actiwatch. We evaluated the changes of each parameter before and 8 weeks after the administration of solifenacin. Statistical comparisons before and after the administration were made using the Wilcoxon signed-rank test. To examine the relation between OABSS and AIS, Spearman's testing was used for correlations between independent variables and P Results Total OABSS and total AIS were significantly improved after administration of solifenacin. The categories of urgency and nocturia in OABSS and the categories of awakening during the night and sleep quality in AIS were also significantly improved. The Actiwatch study showed that total sleep time and sleep efficiency were significantly improved. The decrease of AIS was significantly correlated with the decrease of urgency (ρ = 0.635, P = .0175) but not with nocturia. Conclusion The treatment of urgency by solifenacin may improve not only overactive bladder symptoms but also sleep disturbance.

Solifenacin May Improve Sleep Quality in Patients With Overactive Bladder and Sleep Disturbance

To examine the effect of solifenacin for not only overactive bladder symptoms but also sleep disturbance. Nocturia and urgency are independent factors for sleep disturbance. Fifteen male patients with overactive bladder symptoms and sleep disturbance were enrolled in this study. The overactive bladder symptoms score (OABSS) and Athens insomnia scale (AIS) were used as a subjective questionnaire for overactive bladder symptoms and insomnia. The Actiwatch-16 (Mini-Mitter-Respironics, Inc., Bend, OR) was used as an objective measurement tool for insomnia. Total sleep time, sleep efficiency, sleep latency, wake-after-sleep onset, and number of awakenings were measured by the Actiwatch. We evaluated the changes of each parameter before and 8 weeks after the administration of solifenacin. Statistical comparisons before and after the administration were made using the Wilcoxon signed-rank test. To examine the relation between OABSS and AIS, Spearman's testing was used for correlations between independent variables and P<.05 was considered statistically significant. Total OABSS and total AIS were significantly improved after administration of solifenacin. The categories of urgency and nocturia in OABSS and the categories of awakening during the night and sleep quality in AIS were also significantly improved. The Actiwatch study showed that total sleep time and sleep efficiency were significantly improved. The decrease of AIS was significantly correlated with the decrease of urgency (ρ=0.635, P=.0175) but not with nocturia. The treatment of urgency by solifenacin may improve not only overactive bladder symptoms but also sleep disturbance.

(A77) Should Response Times continue to be used for Performance Measurement and Targets?

PurposeResponse time performance for emergency calls has been used as an indicator of ambulance service quality in England since 1974. It was revised in 1996 with targets set of eight minutes for life-threatening (category A) and 19 minutes for urgent (category B) calls. Internationally, response time has been used as the benchmark for emergency medical services (EMS) performance. The evidence to support use of response times as a quality measure has been examined.MethodsA rapid review was used to assess the evidence base for the eight minute response time target. Also, a descriptive observational study of the clinical characteristics of category B calls was performed using two months patient report form data from one English ambulance service.ResultsFive papers were identified that have examined the relationship between response time and mortality for 911/999 emergency call populations. Four papers were from the USA, and in all cases no survival benefit was found for response times &gt; 5 minutes even after adjustment for variables including age, sex and illness severity. This finding was replicated in one UK study. The descriptive study examined call characteristics for 26,882 category B calls. Half of the patients received no intervention other than basic vital signs measurement and 75% had assessment only. Twenty-five percent required some clinical intervention with the majority only requiring oxygen. Less than 5% received significant intervention such as drugs, intravenous cannula, or airway management.ConclusionsWith the exception of cardiac arrest there is consistent evidence that response time has no impact on mortality for EMS calls. Alternative indicators of quality of care should be developed that allow less focus on time targets and more effort on innovation and development of services which could better meet the needs of the majority of patients who do not have a life-threatening problem.

(A47) Pediatric Mass-Casualty Triage: The New York City Approach

IntroductionA Mass-Casualty Event (MCE) involving pediatric victims could overwhelm existing pediatric resources. Therefore, early recognition of critically ill infants and children is essential for proper distribution among pediatric capable hospitals. However, emergency medical services (EMS) personnel have limited experience with pediatric assessments, and less with pediatric mass-casualty triage (MCT). To address these gaps, the New York City (NYC) Pediatric Disaster Coalition (PDC) in collaboration with the Fire Department (FDNY) and Office of Emergency Management, made simple alterations to the START-based NYC-MCT Algorithm that can be rapidly and accurately applied by EMS personnel in the field with minimal additional education and preparation, obviating the requirement for extensive and expensive retraining.MethodsThe PDC includes experts in pediatric emergency preparedness, emergency medicine, critical care, and trauma surgery in NYC, as well as DOHMH, FDNY-OMA, and OEM. Its Triage Subcommittee determined the minimum essential pediatric alterations to the Algorithm, which then was tested by FDNY-EMS.ResultsAfter focused literature review and multiple draft revisions aimed to maximize pediatric benefit yet minimize unnecessary complexity, the Algorithm was modified to ensure that: (1) five rescue breaths will be provided to infants or children prior to being categorized as Dead or Expectant; (2) infants under 12 months old will be categorized as Critical and receive priority transport, and (3) children initially categorized as Delayed or Minor will be uptriaged to a new Urgent (Orange) category to receive such care in a rapid manner. To date, &gt; 3,000 FDNY personnel have been trained in its use, and tested its accuracy using tabletop scenarios. Mean accuracy is 80–90%.ConclusionsThe model is an effective, multidisciplinary approach to planning. Minimum alterations to the Algorithm were adopted by the regional EMS system. The Modified Algorithm improves identification of critically ill infants and children. This approach could be adopted by other large urban centers.