Emergency Department Triage Process Research Articles

Effect of Paramedics in Emergency Department Triage on Ambulance Patient Offload Times

Background: Emergency Department (ED) overcrowding limits patient care in the prehospital and hospital system. A program was implemented to decrease the time to patient handoff from EMS arrival to ED staff, also known as the delivery interval and total turnaround interval. Paramedics were added to the ED ambulance triage staff to receive verbal reports and perform certain tasks done traditionally by nurses. We hypothesized adding paramedics to the ED triage process would reduce delivery interval times and total turnaround times. Methods: This was a retrospective observational study comparing delivery and turnaround intervals for patients brought to the ED by ambulance, before and after the addition of a paramedic in triage. The study period included all adult ED patients brought in by ambulance between 11 AM and 11 PM. Pediatric patients (<21 years old), direct-to-inpatient interfacility transfers, and critical patients requiring immediate care in the resuscitation area and thus bypassing normal triage processes were excluded. The data was analyzed with two-sample t-tests with a confidence interval of a = 0.05. Results: Delivery interval pre-implementation of the program was 15:48 minutes (95% CI [15:28, 16:09]) compared to 14:04 minutes (95% CI [13:44, 14:25]) post-implementation. The mean turnaround interval pre-implementation was 35:21 minutes (95% CI [35:01, 35:42]) and 36:04 minutes (95% CI [35:40, 36:29]) post-implementation. The mean difference for the delivery interval was shortened by 01:44 minutes (p<0.0001; 95% CI [01:15, 02:13]). The mean turnaround interval increased by 00:43 seconds (p<0.01; 95% CI [00:11, 01:16]). Conclusion: Staffing a paramedic in ED triage decreased delivery interval by 1:44 minutes but did not affect ambulance turnaround times. Further research is needed to determine if the decrease in delivery interval improved patient outcomes and ways to translate the time saved in the delivery interval to total turnaround times.

Improved patient mortality predictions in emergency departments with deep learning data-synthesis and ensemble models

The triage process in emergency departments (EDs) relies on the subjective assessment of medical practitioners, making it unreliable in certain aspects. There is a need for a more accurate and objective algorithm to determine the urgency of patients. This paper explores the application of advanced data-synthesis algorithms, machine learning (ML) algorithms, and ensemble models to predict patient mortality. Patients predicted to be at risk of mortality are in a highly critical condition, signifying an urgent need for immediate medical intervention. This paper aims to determine the most effective method for predicting mortality by enhancing the F1 score while maintaining high area under the receiver operating characteristic curve (AUC) score. This study used a dataset of 7325 patients who visited the Yonsei Severance Hospital’s ED, located in Seoul, South Korea. The patients were divided into two groups: patients who deceased in the ED and patients who didn’t. Various data-synthesis techniques, such as SMOTE, ADASYN, CTGAN, TVAE, CopulaGAN, and Gaussian Copula, were deployed to generate synthetic patient data. Twenty two ML models were then utilized, including tree-based algorithms like Decision tree, AdaBoost, LightGBM, CatBoost, XGBoost, NGBoost, TabNet, which are deep neural network algorithms, and statistical algorithms such as Support Vector Machine, Logistic Regression, Random Forest, k-nearest neighbors, and Gaussian Naive Bayes, as well as Ensemble Models which use the results from the ML models. Based on 21 patient information features used in the pandemic influenza triage algorithm (PITA), the models explained previously were applied to aim for the prediction of patient mortality. In evaluating ML algorithms using an imbalanced medical dataset, conventional metrics like accuracy scores or AUC can be misleading. This paper emphasizes the importance of using the F1 score as the primary performance measure, focusing on recall and specificity in detecting patient mortality. The highest-ranked model for predicting mortality utilized the Gaussian Copula data-synthesis technique and the CatBoost classifier, achieving an AUC of 0.9731 and an F1 score of 0.7059. These findings highlight the effectiveness of machine learning algorithms and data-synthesis techniques in improving the prediction performance of mortality in EDs.

Electronic Diagnostic Support in Emergency Physician Triage: Qualitative Study With Thematic Analysis of Interviews.

BackgroundNot thinking of a diagnosis is a leading cause of diagnostic error in the emergency department, resulting in delayed treatment, morbidity, and excess mortality. Electronic differential diagnostic support (EDS) results in small but significant reductions in diagnostic error. However, the uptake of EDS by clinicians is limited.ObjectiveWe sought to understand physician perceptions and barriers to the uptake of EDS within the emergency department triage process.MethodsWe conducted a qualitative study using a research associate to rapidly prototype an embedded EDS into the emergency department triage process. Physicians involved in the triage assessment of a busy emergency department were provided the output of an EDS based on the triage complaint by an embedded researcher to simulate an automated system that would draw from the electronic medical record. Physicians were interviewed immediately after their experience. Verbatim transcripts were analyzed by a team using open and axial coding, informed by direct content analysis.ResultsIn all, 4 themes emerged from 14 interviews: (1) the quality of the EDS was inferred from the scope and prioritization of the diagnoses present in the EDS differential; (2) the trust of the EDS was linked to varied beliefs around the diagnostic process and potential for bias; (3) clinicians foresaw more benefit to EDS use for colleagues and trainees rather than themselves; and (4) clinicians felt strongly that EDS output should not be included in the patient record.ConclusionsThe adoption of an EDS into an emergency department triage process will require a system that provides diagnostic suggestions appropriate for the scope and context of the emergency department triage process, transparency of system design, and affordances for clinician beliefs about the diagnostic process and addresses clinician concern around including EDS output in the patient record.

Investigating racial disparities within an emergency department rapid-triage system

ObjectivesRacial disparities in emergency medical care are abundant, and processes aimed to increase throughput, such as a rapid triage fast-track (FT) systems, may exacerbate these inequities. A FT strategy may be more susceptible to implicit bias as subjective information is obtained quickly. We aim to determine whether a FT model was associated with greater disparities between Black and White emergency department (ED) patients. MethodsTriage-related outcomes were compared across race using a cohort selected from encounters in an ED that uses a FT model. White and Black patient encounters were exact-matched on potential confounders including sex; presence of abnormal vital signs; ED arrival time; insurance type; age category; and chief complaint. The primary triage-related outcome was use of the FT area (versus the main ED), and the secondary outcomes were wait time and assigned encounter acuity. ResultsEncounters for 5151 Black patients were exact-matched with 7179 encounters for White patients. Weights were applied to address differential numbers of encounters from each group. Within this matched cohort, Black patients were more likely to be triaged to FT than White patients (odds ratio = 1.28, 95% CI: 1.12; 1.46) and less likely to be given a high acuity score (odds ratio = 0.73, 95% CI: 0.66, 0.81). Among the high-acuity patients, Black patients were 40% more likely to be triaged to the FT area. ConclusionsThese results suggest that, after controlling for potential confounders, racial disparities may have been exacerbated in a FT ED triage process. In a FT model utilizing physicians and midlevel providers, this may create tiered levels of care between Black and White patients – an unacceptable side-effect of an effort to increase ED throughput.

Coupling Wearable Devices and Decision Theory in the United States Emergency Department Triage Process: A Narrative Review.

This research was motivated by the nurses’ decision-making process in the current emergency department (ED) triage process in the United States. It explores how continuous vital signs monitoring can be integrated into the ED. The article presents four shortcomings on current ED triage systems and proposes a new conceptual clinical decision support model that exploits the benefits of combining wireless wearable devices with Multi-Attribute Utility Theory to address those shortcomings. A literature review was conducted using various engineering and medical research databases, analyzing current practices and identifying potential improvement opportunities. The results from the literature review show that advancements in wireless wearable devices provide opportunities to enhance current ED processes by monitoring patients while they wait after triage and, therefore, reduce the risk of an adverse event. A dynamic mathematical decision support model to prioritize patients is presented, creating a feedback loop in the ED. The coupling of wearable devices (to collect data) with decision theory (to synthesize and organize the information) can assist in reducing sources of uncertainty inherent to ED systems. The authors also address the feasibility of the proposed conceptual model.

Effects of environmental distractors on nurse emergency triage accuracy: a pilot study protocol

BackgroundThe clinical decisions of emergency department triage nurses need to be of the highest accuracy. However, studies have found repeatedly that these nurses over- or underestimate the severity of patient health conditions. This has major consequences for patient safety and patient flow management. Workplace distractors such as noise and task interruptions have been pointed to as factors that might explain this inaccuracy. The use of a serious game reproducing the work environment during triage affords the opportunity to explore the impact of these distractors on nurse emergency triage accuracy, in a safe setting.Methods/designA pilot study with a factorial design will be carried out to test the acceptability and feasibility of a serious game developed specifically to simulate the triage process in emergency departments and to explore the primary effects of distractors on nurse emergency triage accuracy. Eighty emergency nurses will be randomized into four groups: three groups exposed to different distractors (A, noise; B, task interruptions; C, noise and task interruptions) and one control group. All nurses will have to complete 20 clinical vignettes within 2 h. For each vignette, a gold standard assessment will be determined by experts. Pre-tests will be conducted with clinicians and certified emergency nurses to evaluate the appeal of the serious game.DiscussionStudy results will inform the design of large-scale investigations and will help identify teaching, training, and research areas that require further development.

P097: The emergency department experience for patients and caregivers referred from an outpatient oncology clinic

Introduction: Outpatient oncology clinics have become the mainstay of cancer treatment, but their limited services and hours of operation often lead to emergency department (ED) referrals. With Canada's aging population and cancer survival rates improving, cancer-related ED visits are becoming a significant aspect of emergency medicine. A cancer-related visit to the ED is associated with unique challenges for patients, their caregivers and clinicians. This study focuses on understanding the ED experience of patients and their caregivers sent from an outpatient oncology clinic to a separate affiliated large academic hospital. Methods: A descriptive, phenomenological study of interviews was conducted using the method of Giorgi. The sample included 12 participants (n = 9 patients, 3 caregivers) referred to the ED at a large academic hospital (i.e., Toronto General Hospital, TGH) following a same-day outpatient oncology appointment at an affiliated cancer centre (i.e., Princess Margaret Hospital, PMH). Interviews continued until thematic saturation. All transcripts were analyzed by 2 reviewers with bracketing to ensure accuracy. Results: Four themes were identified from analysis: (1) communication; (2) expectations; (3) care and symptom management and (4) potential improvements. Overall patients and caregivers felt communication between PMH and TGH, and from providers could have been better. Many felt there was a break-down in communication as they did not expect to go through the usual ED triage process, which caused additional anxiety and frustration with the wait times. The majority felt their symptoms were managed in a timely manner and reported the staff to be friendly, caring and professional; however, often felt forgotten and anxious due to a lack of “checking-in”. Their experience could have been improved by receiving more information on the process, a more welcoming environment and separate waiting area or private room for those who are immunocompromised. Conclusion: Although referral from an outpatient oncology clinic to the ED of an affiliated hospital is a common process within Canada, this is the first study to explore the patient and caregiver experience. Understanding the patient and caregiver experience is valuable for identifying quality improvement initiatives. Our analysis revealed the patient and caregiver experience could be improved with better communication and expectation setting regarding the ED process before and throughout the visit.

Creation of a global emergency-department research network: a feasibility study

BackgroundThe epidemiology of emergency care globally is largely unknown, especially in developing countries, because of a lack of common taxonomy, an absence of robust reporting mechanisms, and because emergency medicine is not always recognised as a subspecialty in its own right. Other disease-specific and specialty-specific research networks have addressed these barriers and brought about improved health of populations as a result. The University of Michigan's Department of Emergency Medicine is developing an international emergency-department research network to study the epidemiology of emergency visits in developed and developing countries. Our objectives are: to describe the first steps taken in creation of an international emergency-department research network; to discuss lessons learned; and propose a feasibility pilot study to determine epidemiology of emergency department visits across ten emergency departments in eight countries. MethodsWe contacted emergency departments that have a training programme for emergency medicine and have an existing collaboration with the University of Michigan's Global Reach programme in China, India, Ghana, Brazil, Taiwan, Austria, Finland, and the USA. We conducted a survey of research-related resources and electronic data access to determine whether sites were suitable for inclusion in the network. Finally, we proposed a feasibility study to measure interest in the project at sites as well as their ability to participate. FindingsWe noticed substantial variation between sites with respect to: the emergency department triage process; access to consultants; definitions of levels of severity of illness; management of resuscitation; and discharge disposition, even for the same condition. We developed a manual of operations, standard taxonomies, and are working on Institutional Review Board approval and data transfer agreements. We will be enrolling patients in prospective and retrospective studies with a sparse simultaneous-sampling design over a period of 6 months. The data collected will have ongoing quality checks to confirm validity and reliability. InterpretationDespite some substantial barriers, development of an infrastructure to study emergency care at a global level is feasible. The sustainability plan is to create a robust network that nurtures future investigators, identifies funding sources, and works on collaborative research. We anticipate challenges in collecting baseline data on emergency department presentations, so have designed two pathways to collect data: a retrospective Electronic Health Record query; and prospective data collection in real-time. We are planning an in-person meeting to establish standard processes for research priorities and resource allocation. FundingNone.

Implementing best practice into the emergency department triage process.

Triage is the process by which emergency departments (EDs) sort patients presenting for medical treatment. The Australasian Triage Scale, validated to measure urgency, answers the question 'This patient should wait for medical assessment and treatment no longer than…' Multiple patients may present within short time frames, and some will have conditions that have outcomes directly related to timeliness of treatment such as stroke, sepsis and myocardial infarction. The safety of patients within the ED is thus directly related to the triage system. This project aimed to compare current triage practice within a metropolitan ED with evidence-based practice guidelines produced by the Australasian College for Emergency Medicine and College of Emergency Nurses Australasia. The clinical audit project was undertaken in an ED in a large metropolitan hospital. Two hundred episodes of triage were audited, 100 in the preimplementation and 100 in the postimplementation phase. Current practice was compared with triage guidelines, barriers to adherence to evidence-based practice identified, and interventions were planned and implemented to address these. The audits of practice focused on five key areas and were assessed against 12 criteria: arrival and triage, documentation, compliance with policy, communication, and triage staff. Overall five criteria showed improvement, with reassessment of patients waiting for treatment, and the time taken for each triage episode achieving the greatest amount of improvement. Four criteria showed no improvement or a decline, and two achieved 100% adherence in both audits. The project sought to undertake a clinical audit of triage practice to evaluate the adherence of practice to evidence-based guidelines. The project has provided strong support for the implementation of a formal nursing role to support the care of waiting room patients, and act as a second triage nurse during periods of high activity. The physical triage environment has been identified as a barrier to optimal adherence to evidence-based practice guidelines. Using effective communication to manage the waiting experience of patients can have positive benefits for both patients and staff. WHAT DOES THIS ARTICLE ADD.

Configurations of factors affecting triage decision-making

PurposeThe purpose of this paper is to explore the configuration of factors affecting the accuracy of triage decision-making. The contribution of the work is twofold: first, it develops a protocol for applying a fuzzy-set qualitative comparative analysis (fsQCA) in the context of triage decision-making, and second, it studies, through two pilot cases, the interplay between individual and organizational factors in determining the emergence of errors in different decisional situations.Design/methodology/approachThe methodology adopted in this paper is the qualitative comparative analysis (QCA). The fuzzy-set variant of QCA (fsQCA) is implemented. The data set has been collected during field research carried out in the Emergency Departments (EDs) of two Italian public hospitals.FindingsThe results of this study show that the interplay between individual and contextual/organizational factors determines the emergence of errors in triage assessment. Furthermore, there are some regularities in the patterns discovered in each of the investigated organizational contexts. These findings suggest that we should avoid isolating individual factors from the context in which nurses make their decisions.Originality/valuePrevious research on triage has mainly explored the impact of homogeneous groups of factors on the accuracy of the triage process, without considering the complexity of the phenomenon under investigation. This study outlines the need to consider the not-linear relationships among different factors in the study of triage’s decision-making. The definition and implementation of a protocol to apply fsQCA to the triage process in EDs further contributes to the originality of the research.

Use of ReDS Technology to Triage Heart Failure Patients in the Emergency Department

Background Reducing heart failure (HF) readmissions has become an important, but elusive, goal for many hospital systems. The Emergency Department (ED) is the final common pathway through which patient stabilization occurs and where disposition decisions are made. Thus, improving triage of HF patients in the ED may provide an effective way to reduce the rate of HF readmissions. The Remote Dielectric Sensing (ReDS) Wearable System is an FDA-approved device developed by Sensible Medical Innovations that allows clinicians and other health care providers to accurately, quickly and non-invasively measure lung fluid. Methods At MCHS, about 88% of patients seeking care for SOB with history of HF are admitted to the hospital for inpatient treatment. This identified a need to develop a tool to assist in risk stratification. The primary outcome was to provide an objective measure to aid in making a disposition decision. The secondary outcome was to determine the percentage of patients who present to the ED with signs and symptoms of acute HF and fall into the mild, moderate, or high risk categories.• ReDS reading of Results We assessed 39 HF patients presenting to the ED with complaints of worsening HF symptoms. Each underwent a ReDS reading during the ED triage process. Conclusion In our pilot study, implementing a ReDS assessment into the ED triage process was feasible. Most patients who present to ED with SOB and history of HF are either significantly volume overloaded and require an inpatient admission for diureses or have SOB from a non-HF cause. Adequate ED treatment and close HF clinic follow up may be a safe and effective resource utilization for those patients with moderately elevated volume to prevent an inpatient admission.

Impact of Alcohol Screening for Traumatic Brain Injury Patients Being Admitted to Neurosurgical Intensive Care Unit

The aims of this study were to determine the prevalence and describe the importance of alcohol screening for all patients with traumatic brain injury (TBI) and examine the relationship between gender, age, Abbreviated Injury Scale (AIS), emergent decompressive craniectomy, Glasgow Coma Scale (GCS) from the emergency department (ED), and the length of stay with alcohol screening. This is a retrospective analysis of de-identified data from the 2012 TBI registry of a level 1 trauma center in the Pacific Northwest. Of 1591 patients with TBI, 1273 (80%) were screened for alcohol use and 318 (20%) were not screened. There was a significant association between alcohol screening and AIS (χ(5) = 15.46, P < .001), ED GCS (χ(12) = 22.13, P = .04), sex (χ(1) = 7.86, P ≤ .001), and age (r = 0.23, P < .001). Women and patients with high AIS (critical), low (mild) AIS, and midrange GCS scores were less likely to be screened, as were younger patients. Urgent decompressive craniectomy (χ(1) = 1.94, P = .16) and length of stay (r = -0.04, P = .14) did not display a significant association with alcohol screening. This study uncovered a systemic bias per sex and age for alcohol screening, as well as skewed AIS and GCS scores due to an unknown alcohol intoxication status. An updated ED's triage process and screening tool is recommended to achieve a targeted 100% alcohol screening rate for all head trauma patients in the ED before admission to the neurosurgical intensive care unit.

Triage process in Emergency Departments: an Indonesian Study

Triage process in Emergency Departments: an Indonesian Study

Thinking strategies used by Registered Nurses during emergency department triage

This paper is a report of a study to describe and compare thinking strategies and cognitive processing in the emergency department triage process by Registered Nurses with high and low triage accuracy. Sound clinical reasoning and accurate decision-making are integral parts of modern nursing practice and are of vital importance during triage in emergency departments. Although studies have shown that individual and contextual factors influence the decisions of Registered Nurses in the triage process, others have failed to explain the relationship between triage accuracy and clinical experience. Furthermore, no study has shown the relationship between Registered Nurses' thinking strategies and their triage accuracy. Using the 'think aloud' method, data were collected in 2004-2005 from 16 RNs working in Swedish emergency departments who had previously participated in a study examining triage accuracy. Content analysis of the data was performed. The Registered Nurses used a variety of thinking strategies, ranging from searching for information, generating hypotheses to stating propositions. They structured the triage process in several ways, beginning by gathering data, generating hypotheses or allocating acuity ratings. Comparison of participants' use of thinking strategies and the structure of the triage process based on their previous triage accuracy revealed only slight differences. The wide range of thinking strategies used by Registered Nurses when performing triage indicates that triage decision-making is complex. Further research is needed to ascertain which skills are most important in triage decision-making.