Correct Triage Research Articles

Development of a Decision Support Tool to Guide Management of Adults with Sickle Cell Disease: The Emergency Department Sickle Cell Assessment of Strengths and Needs (ED-SCANS).

Abstract 1413Poster Board I-436 Objectives:There are relatively few centers across the United States that either specialize in SCD care or have day hospitals where patients can be evaluated and urgently treated for acute pain crises. While most patients come to the ED for management of an acute pain crisis, SCD patients are at risk for many life-threatening complications. Most patients with SCD require an ED visit at some point. The complexity of SCD warrants a comprehensive assessment in the emergency department. While it may be challenging to conduct such an assessment in the ED, a succinct decision support tool may help guide clinicians in the performance of such an assessment. The benefits of such an assessment would identify unmet patient needs and help guide ED management and referrals. The goal of this project was to develop a brief, easy to use tool that guides the emergency clinicians in the identification of such needs and aid in accomplishing the following goals: 1) rapidly and aggressively manage ED pain, 2) identify other life-threatening conditions, 3) decrease hospital admission rates, 4) decrease return visits to the ED, 5) identify and increase the number of referrals made from the ED setting, and 6) increase both patient and clinician satisfaction with the ED experience. Methods:A series of seven clinician and patient focus groups were conducted in four cities across the United States (Chicago, Denver, Durham, and New York) to obtain key stakeholder input. Visits at three SCD centers of excellence (University of Colorado Denver, Duke University, Virginia Commonwealth University) were conducted, a literature search was conducted, and the PI attended SCD clinics to observe practice patterns with sickle cell experts at the University of Illinois and University of Chicago sickle cell clinics. Focus group data was analyzed using qualitative methods and is reported elsewhere. All data was synthesized and a draft tool was created and reviewed by outside experts. Revisions were made. Results:The following six key decisions were identified as being critical in achieving the tools aims: (1) what is the correct triage level, (2) how should pain be treated, (3) does the patient require a diagnostic work-up, (4) should the patient be admitted to the hospital, (5) if discharged home, is there a need for analgesic prescriptions, and (6) does the patient need a referral to a sickle cell expert or mental health or social services? Supporting data elements for each decision were also identified and included as part of the tool which will be formulated into an easy to use algorithm. Data elements include key history and physical indicators of a potential high risk situation necessitating further evaluation, pain assessment and history of analgesic use, relationship with a sickle cell expert, ED and hospital utilization history, and evaluation of psychosocial needs (self-report of anxiety or depression, work/employment status, home situation). Conclusions:Critical decisions and associated supporting elements to facilitate ED management were identified. Future work will involve finalizing and testing this communimetric tool, which will guide emergency department evaluation and management, as well as guide analgesic management in real time. Disclosures:Tanabe: NIH, and Mayday Fund: Research Funding. Todd: NIH: Research Funding; Xanodyne: Consultancy; Merck: Consultancy; Alpharma: Consultancy; Abbott: Consultancy; Baxter Healthcare: Consultancy; Fralex Therapeutics: Consultancy; Intranasal Therapeutics: Consultancy; Baxter Health: Research Funding; Roxro: Consultancy.

OP24.08: Intraobserver and interobserver agreement of color Doppler in adnexal malignancy

S-BOT (p = 0.05). M-BOT had echogenic fluid more than S-BOT, but this difference did not reach statistical significance. Only in 5/11 tumors (45%) a significant blood flow was documented. 11/23 (47%) tumors were correctly triaged for oncology-related surgery procedure based on clinical and sonographic evaluation. Conclusions: Echogenic fluid, multilocularity and a larger diameter is more typical to M-BOT. Papillary projections are more often associated with S-BOT. Correct triage for an oncology-related surgery, based on these factors, seem less successful than expected.

OP24.10: GI-RADS: a new proposal for classifying adnexal masses based on sonographic findings

S-BOT (p = 0.05). M-BOT had echogenic fluid more than S-BOT, but this difference did not reach statistical significance. Only in 5/11 tumors (45%) a significant blood flow was documented. 11/23 (47%) tumors were correctly triaged for oncology-related surgery procedure based on clinical and sonographic evaluation. Conclusions: Echogenic fluid, multilocularity and a larger diameter is more typical to M-BOT. Papillary projections are more often associated with S-BOT. Correct triage for an oncology-related surgery, based on these factors, seem less successful than expected.

7024 Phase Ib dose-finding trial of intravenous (i.v.) panobinostat (PAN) with docetaxel (DOC) and prednisone (PRED) in patients (pts) with castration resistant prostate cancer (CRPC)

Rapid care protocols developed to reduce in-hospital delay times in the assessment of acute stroke patients are now common in Emergency Departments. Correct triage identification and prioritisation is vital to instigate this process and increase the eligibility of patients for acute stroke treatments.We set out to examine triage assessments of acute stroke patients and investigate factors associated with the instigation of rapid care protocols (allocation of triage category 1 or 2) for acute stroke patients presenting within 2 h of symptom onset.A retrospective assessment of emergency department records was undertaken for stroke patients presenting to three hospitals in Melbourne over six months in 2010.798 patients were included in the study. Among acute stroke patients who presented within 2 h (n = 185), 173 (94%) were identified as stroke at triage with 10 cases identified as “altered conscious state”. In all cases not identified as stroke the patient was diagnosed with intracerebral haemorrhage. 132 cases (71%) were allocated a triage category 1 or 2. Facial weakness (p = 0.002) and presentation to Monash Medical Centre (p = <0.001), were significantly associated with triage category 1 or 2.Virtually all acute stroke patients were identified at triage, however 30% were not allocated an urgent triage category (1 or 2). Further education strategies may be required to develop awareness of rapid care protocols for acute stroke patients among triage nurses and ensure the uniform application of Acute Stroke Guidelines and local rapid care pathways.

Does START Triage Work? An Outcomes Assessment After a Disaster

The mass casualty triage system known as simple triage and rapid treatment (START) has been widely used in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients' actual clinical status. Researchers hypothesize that START achieves at least 90% sensitivity and specificity for each triage level and ensures that the most critical patients are transported first to area hospitals. The performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment. Investigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventy-nine patients were overtriaged, 3 were undertriaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). The Obuchowski statistic was 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category. The median arrival time for red patients was more than 1 hour earlier than the other patients. This analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of undertriage (100% red sensitivity and 89% green specificity) but incorporated a substantial amount of overtriage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.

Reliability of the Primary Triage Process after the Volendam Fire Disaster

In a major incident, correct triage is crucial to emergency treatment and transportation priority. The aim of this study was to evaluate the triage process pursued at the site of the fire disaster in Volendam, the Netherlands on January 1, 2001. On-site (OS) and Emergency Department (ED) data regarding total body surface area burned (TBSA) and inhalation injury (INH) were compared with the final (FIN) assessment of these two parameters after hospital admission. Finally, the effect of OS intubation and the time of arrival at a hospital were evaluated. There were 245 injured. Mean age was 17.3 years. Final median TBSA was 12%; 96 patients (39%) had inhalation injury. Agreement between TBSA-OS (n = 46) and TBSA-FIN was poor (Pearson's correlations coefficient [PCC] = 0.77; R 2 = 0.60). TBSA-ED (n = 78) was more accurate (PCC = 0.96; R 2 = 0.93). INH-OS (n = 79, sensitivity 100%, specificity 24%) and INH-ED (n = 198, sensitivity 99%, specificity 36%) were sensitive but not specific. Eight patients were intubated on-site. No differences in outcome were found between this group and the patients who were intubated in the hospital. There was no difference in time of arrival at a hospital ( p = 0.55). TBSA was not estimated reliably in a non-clinical environment. The diagnosis of inhalation injury was adequate but resulted in over-triage on-site and at the ED. Triage did not lead to transport priorities for the severely wounded. In a major burn accident, a field triage protocol for rapid evaluation of burn injuries may be useful. Detailed assessment of injuries of burn casualties is practical only in a specialized clinical setting.

Prospective evaluation of the MET-AP system providing triage plans for acute pediatric abdominal pain

Background Children with acute abdominal pain (AP) are frequently assessed in the Emergency Department (ED). Though the majority of patients have benign causes, uncertainty during the physician's initial assessment may result in unnecessary tests and prolonged observation before a definitive disposition decision can be made. A rule-based mobile clinical decision support system, Mobile Emergency Triage-Abdominal Pain (MET-AP), has been developed to recommend an appropriate triage plan (discharge, consult surgery or observe/investigate) early in the ED visit, with the goal of promoting ED efficiencies and improved patient outcomes. Objective To prospectively evaluate the accuracy of MET-AP to recommend the correct triage plan when used during the initial assessment by staff emergency physicians (EPs) and residents in a tertiary care pediatric ED. Design Prospective cohort study. Staff EPs and/or residents examined children, aged 1–16 years, with acute, non-traumatic AP of less than 10 days duration. Details of their initial assessment, along with their blinded prediction of the correct triage plan, were recorded electronically. Inter-observer assessments were collected, where possible. Telephone and chart follow-up at 10–14 days was conducted to determine the patient's outcome/diagnosis, and thus the gold standard triage plan appropriate for the patient's visit. Measurements Accuracy of MET-AP to recommend the correct triage plan (i.e., to match the gold standard plan); accuracy of physicians to predict the correct triage plan; inter-observer agreement between staff EPs and residents for each clinical attribute recorded within MET-AP. Results Over 8 months, 574 patients with AP completed follow-up (10% appendicitis, 13% other pathology, 77% benign/resolving conditions). For patient assessments by the staff EP ( n = 457), the MET-AP recommendation was correct for 72% of patients (95% CI's: 67.9–76.1), while the physician's prediction was correct in 70% of cases (65.9–74.2) ( p = 0.518). However, staff EP triage plans were more conservative than those generated by MET-AP, and a small number of patients whose triage plan should have been “consult surgery” would have been “discharged” by MET-AP. For resident assessments ( n = 339), MET-AP and physician accuracies were slightly lower, but not statistically different from staff results or from each other. Inter-observer agreement on most attributes was moderate to near perfect. Conclusion MET-AP shows promise in recommending the correct triage plan with similar overall accuracy to experienced pediatric EPs, but requires further research to improve accuracy and safety. MET-AP can be used on all pediatric ED patients with AP and is capable of producing a triage plan recommendation without requiring a complete set of patient information.

Echocardiography in the Emergency Department

In the busy emergency department, time-effective and accurate diagnostic and prognostic evaluation is essential Although clinical examination remains the mainstay of appropriate evaluation, remaining diagnostic uncertainty may need to be resolved by use of additional techniques. Echocardiography appears very well suited to the unique environment in the emergency department. It is portable to the patient's bedside, can be performed in minimal time, and results are immediately available. This facilitates correct triage and disposition of complicated cases. Small, hand-carried echocardiography systems have been developed with full imaging and Doppler capabilities. Thus, availability of echocardiography is increasing. Because both image acquisition and interpretation are operator-dependent, realization of full diagnostic potential requires extensive training and post-training experience to maintain proficiency.

German Society of Cytology and Study Group “Cytopathology” of the German Society of Pathology, Abstract 118–125, Posters

Fine needle aspiration cytology (FNAC) can be a precious tool for the evaluation of lymphadenopathies in children and adolescents. The purpose of this study was to analyse the diagnostic accuracy of FNAC in a paediatric lymph node series. We report a series of 76 patients, aged up to 19 years, who underwent lymph node FNAC. In our series, 57 cases were diagnosed as non-neoplastic, including benign reactive hyperplasia and other inflammatory lesions, 18 cases were diagnosed as malignant and 1 case was diagnosed as suspicious for lymphoproliferative process, not otherwise specified. Sensitivity, specificity, positive predictive value and negative predictive value were 93 %, 100 %, 100 % and 98 %, respectively. Diagnostic accuracy resulted 98.6 %. FNAC is an accurate, minimally invasive method with minimal complications that allows evaluation of paediatric lymphadenopathies and a correct triage of reactive/inflammatory and neoplastic lymphadenopathies. The application of rapid on-site evaluation, the realization of a cell block and the application of ancillary diagnostic tests, including at least immunocytochemistry and flow cytometry, allows to achieve an excellent diagnostic performance.

Preanalytical Factors in the Measurement of Intact Parathyroid Hormone with the DPC IMMULITE Assay

Intact parathyroid hormone (iPTH) is commonly measured with two-site immunometric assays. The DPC IMMULITE 2000 assay (Diagnostics Products Corporation) measures iPTH by a chemiluminescence reaction with a monoclonal murine capture antibody and a polyclonal caprine signal antibody conjugated to alkaline phosphatase. Accurate and precise iPTH measurements are needed for the correct triage of individuals with hyper- or hypocalcemia and for the evaluation of PTH function in bone and mineral disorders (1)(2). In end-stage renal failure, iPTH measurements are commonly used to determine medical management (administration of vitamin D) and surgical therapeutic options (subtotal parathyroidectomy for extreme hyperparathyroidism) (3)(4). Collection of whole blood into EDTA-containing sample tubes offers increased iPTH stability at room temperature (5) compared to serum samples (6) and is recommended by the manufacturer of the DPC IMMULITE 2000 iPTH assay. However, insufficient sample volume can lead to increased final EDTA concentration in the sample-reagent mixture, causing chelation of metallic cations, and this can affect the activity of the alkaline phosphatase label used …

Clinical Presentation of th patients with Non-traumatic Chest Pain in Emergency Department

Background: Patients with acute non-traumatic chest pain are among the most challenging patients for care by emergency physicians, so the correct diagnosis and triage of patients with chest pain in the emergency department(ED) becomes important. To avoid discharging patients with acute myocardial infarction(AMI) without medical care, most emergency physicians attempt to admit almost all patients with acute chest pain and order many laboratory tests for the patients. But in practice, many patients with non-cardiac pain can be discharged with simple tests and treatment. These patients occupy expensive intensive care beds, substantially increasing financial cost and time of stay at ED for the diagnosis and treatment of myocardial ischemia and AMI. Despite vigorous efforts to identify patients with ischemic heart disease, approximately 2% to 5% of patients presented to the ED with AMI and chest pain are inadvertently discharged. If the cause for the chest pain is known, rapid and accurate diagnosis can be implemented, preventing wastes in time and money and inadvertent discharge. Methods and Results: The medical records of 488 patients from Jan. 1 to Dec. 31, 1997 were reviewed. There were 320(angina pectoris 140, AMI 128) cases of cardiac diseases, and 168(atypical chest pain 56, pneumothorax 47) cases of non-cardiac diseases. The number of associated symptoms were in non-cardiac diseases, in cardiac diseases and in AMI(p

Myoglobin in the early evaluation of acute chest pain.

Two thirds of patients hospitalized to rule out acute myocardial infarction (AMI) are eventually found to have a non-AMI diagnosis, whereas 2% to 8% of patients with AMI are inappropriately discharged from the emergency department. Myoglobin has been shown to increase within 2 to 3 hours of myocardial injury. This study evaluates the usefulness of myoglobin in acute chest pain. Serial blood samples were obtained from 89 suspected AMI patients evaluated in the emergency department. Testing included creatine kinase (CK), a creatine kinase isoenzyme (CK-MB), and myoglobin. Twenty five of 89 patients (28%) had a diagnosis of AMI. The sensitivity of myoglobin for the detection of AMI was 56% at the time of admission and 100% 2 hours after admission. Thirteen of 25 AMI patients (52%) had a positive myoglobin before increases in CK or CK-MB, including one patient discharged from the emergency department. More importantly, the negative predictive value for myoglobin at the time of admission was 83% and was 100% two hours after admission. This potential for 100% predictability in excluding AMI by the use of serial myoglobin determinations will be very helpful in the correct triage of patients presenting with acute chest pain.

Pediatric trauma score: Is it reliable in predicting mortality?

The Pediatric Trauma Score (PTS) is rapidly gaining acceptance for use in prehospital triage. This study examines its reliability in predicting mortality. The charts of the 533 trauma patients hospitalized between 1984–1989 were reviewed and the PTS was calculated for each. There were 3 deaths in 370 patients with PTS >8, while 24 of 163 children with PTS ⩽8 died. Size categorization was found to be overemphasized because of the low mortality (7.7%) in children smaller than 10 kg, although their mean PTS (6.4 ± 2.1) was significantly lower than the mean PTS (9.0 ± 2.2) of children over 10 kg. Forty-nine of 71 surgically treated patients having intra-abdominal organ injuries had a PTS >8. The existing parameters of PTS did not have equal relationships to mortality, and may even all be inadequate in the correct triage of children with blunt abdominal trauma.

The Three Rivers Regatta accident: An EMS perspective

The Three Rivers Regatta accident occurred on August 7, 1988 when a Formula I racing craft collided with shore, injuring 24 spectators. The authors retrospectively examined the prehospital-based response for this multiple-casualty incident that used emergency medical service (EMS) physicians and 32 paramedics stationed at water and land-based posts to triage and evacuate 24 patients in 32 minutes. Patients were transported to 5 hospitals including 4 Level I trauma centers; this was accomplished in 53 minutes. The EMS response was unique in a number of respects. This was a prehospital-based rescue with the entire triage and stabilization phase accomplished by River Rescue units that transported paramedic divers, EMS physicians, and trauma supplies for 30 patients. Also of significance was the inordinate proportion of pediatric patients that accounted for 50% ( 12 24 ) of the cases. Successful medical care was the result of planning based on “Daily Routine Doctrine” or escalation of existing treatment protocol; adequate supplies, personnel and transport adapted to local geography and patient population; communications, including all services—EMS, police, and fire; and prehospital physician input to ensure correct triage order and patient disposition.

Evaluation of possible patient survival in a mock airplane disaster

A mock disaster at Orange County's John Wayne Airport provided a basis for examining correct triage of patients and their arrival time for definitive care. The ability to triage critically injured patients in a timely fashion was found to be only slightly better than chance routing. For most of the seriously and critically injured patients, it took more than 1.5 hours to reach the hospital. Advanced life support with intravenous fluid resuscitation available on the scene would probably reduce the mortality of possible disaster victims by 50 percent. These problems are presently being addressed. In future disaster exercises, the present type of evaluation could be used to judge improvement in possible patient triage and survival.