Triage Tool In Emergency Department Research Articles

Utility of emergency department triage tools in predicting the need for intensive respiratory or vasopressor support in adult patients with COVID-19

BackgroundSerum and radiological parameters used to predict prognosis in COVID patients are not feasible in the Emergency Department. Due to its damaging effect on multiple organs and lungs, scores used to assess multiorgan damage and pneumonia such as Pandemic Medical Early Warning Score (PMEWS), National Early Warning Score 2 (NEWS2), WHO score, quick Sequential Organ Failure Assessment (qSOFA), and DS-CRB 65 can be used to triage patients in the Emergency Department. They can be used to predict patients with the highest risk of seven-day mortality and need for intensive respiratory or vasopressor support (IRVS). PurposeThe primary purpose was to find the score with the highest AUC in predicting IRVS and mortality at seven days. Additional objective was to find out any independent factors associated with IRVS and mortality. MethodsThe data of adult patients who presented to the Emergency Department (ED) between April 1, 2021 and June 30, 2021 were collected. The WHO score, CRB-65, DS-CRB 65, PMEWS, NEWS2, and qSOFA score were calculated for all patients. Statistical analysis was done and an ROC curve was calculated for all the tools for mortality and need for IRVS at seven days. Findings677 patients presented to the Emergency Department with COVID-19 during the period above. Presence of Diabetes Mellitus (p = 0.001), Hypertension (p = 0.001), and chronic kidney disease(CKD) (p = 0.04) was significantly associated with need for IRVS. Age, duration of symptoms, pulse rate, respiratory rate, room air saturation, mental status at admission, and time to IRVS need were identified as independent predictors of in-hospital mortality. The longer the time to IRVS need from ED arrival, the higher the likelihood of mortality. PMEWS (0.830) had the highest AUC, followed by NEWS2 (0.805). A PMEWS cut-off of 6.5 was 74.2% sensitive and 78.3% specific in predicting the need for IRVS. ROC analysis to predict 7-day mortality showed that PMEWS had an AUC of 0.802 (0.766–0.839). QSOFA performed poorly in predicting IRVS (AUC 0.645) and 7-day mortality (AUC 0.677). ConclusionPMEWS may be used for triaging patients presenting to the Emergency Department with COVID-19 and accurately predicts the need for IRVS and seven day mortality.

Promoting eCo-responsibility, eCo-literacy, and eCo-centricity in emergency triAge Regarding climate changE consequences (I-CARE THE 3 Cs): study protocol

Background: Climate change, ambient air pollution, and non-optimal temperatures are recognized as a global health emergency. Many studies have highlighted increases in the number of emergency hospital admissions and hospitalizations for respiratory and cardiovascular diseases associated with non-optimal temperatures, unconventional gas reserves, particulate matter, grounded level O3, sulphur dioxide, or nitrogen dioxide exposure. Problem statement: According to the Swiss Health Observatory, 14% of the Swiss population used a hospital emergency department (ED) at least once in 2016, representing 1,7 million admissions or 4,718 admissions per day. In the face of evolving climate-associated reasons for presenting at the ED, the scales used for emergency triage are now proving insufficient for their task. It is becoming critical to introduce and implement more appropriate ED triage tools that incorporate risk factors such as ambient temperature and air pollution. It will also require raising nurses’ eco-literacy, eco-responsibility, and eco-centricity, which are currently rated as moderate to low, to ensure adaptation and/or mitigation in the face of this global threat. Future directions and perspectives for the nursing discipline: The nursing discipline must develop its eco-literacy, eco-responsibility, and eco-centricity to take social and professional responsibility for addressing the health-related impacts of climate change. To do so, the research project’s overall aim, which will be achieved in five stages, is to develop, pilot-test, and evaluate the feasibility of a complex nursing intervention named “Education Intervention promoting eCo-literacy, eCo-responsibility, and eCo-centricity in emergency triAge Regarding climate changE consequences (I-CARE the 3 Cs). The I-CARE the 3 Cs intervention aims to provide an adequate, effective, efficient, fair, safe, and patient-centered response to patients’ and nurses’ needs and to develop guidelines for dealing with the health consequences of climate change.

Improved interpretable machine learning emergency department triage tool addressing class imbalance.

The Score for Emergency Risk Prediction (SERP) is a novel mortality risk prediction score which leverages machine learning in supporting triage decisions. In its derivation study, SERP-2d, SERP-7d and SERP-30d demonstrated good predictive performance for 2-day, 7-day and 30-day mortality. However, the dataset used had significant class imbalance. This study aimed to determine if addressing class imbalance can improve SERP's performance, ultimately improving triage accuracy. The Singapore General Hospital (SGH) emergency department (ED) dataset was used, which contains 1,833,908 ED records between 2008 and 2020. Records between 2008 and 2017 were randomly split into a training set (80%) and validation set (20%). The 2019 and 2020 records were used as test sets. To address class imbalance, we used random oversampling and random undersampling in the AutoScore-Imbalance framework to develop SERP+-2d, SERP+-7d, and SERP+-30d scores. The performance of SERP+, SERP, and the commonly used triage risk scores was compared. The developed SERP+ scores had five to six variables. The AUC of SERP+ scores (0.874 to 0.905) was higher than that of the corresponding SERP scores (0.859 to 0.894) on both test sets. This superior performance was statistically significant for SERP+-7d (2019: Z = -5.843, p < 0.001, 2020: Z = -4.548, p < 0.001) and SERP+-30d (2019: Z = -3.063, p = 0.002, 2020: Z = -3.256, p = 0.001). SERP+ outperformed SERP marginally on sensitivity, specificity, balanced accuracy, and positive predictive value measures. Negative predictive value was the same for SERP+ and SERP. Additionally, SERP+ showed better performance compared to the commonly used triage risk scores. Accounting for class imbalance during training improved score performance for SERP+. Better stratification of even a small number of patients can be meaningful in the context of the ED triage. Our findings reiterate the potential of machine learning-based scores like SERP+ in supporting accurate, data-driven triage decisions at the ED.

Accuracy of Trauma on Scene Triage Screening Tool (Shock Index, Reverse Shock Index Glasgow Coma Scale and National Early Warning Score) to Predict the Severity of Emergency Department Triage: A Retrospective Cross-Sectional Study.

Prehospital trauma care includes on-scene assessments, essential treatment, and facilitating transfer to an appropriate trauma center to deliver optimal care for trauma patients. While the Simple Triage and Rapid Treatment (START), Revised Triage Sieve (rTS), and National Early Warning Score (NEWS) tools are user-friendly in a prehospital setting, there is currently no standardized on-scene triage protocol in Thailand Emergency Medical Service (EMS). Therefore, this study aims to evaluate the precision of these tools (SI, rSIG, and NEWS) in predicting the severity of trauma patients who are transferred to the emergency department (ED). This study was a retrospective cross-sectional and diagnostic research conducted on trauma patients transferred by EMS to the ED of Ramathibodi Hospital, a university-affiliated super tertiary care hospital in Bangkok, Thailand, from January 2015 to September 2022. We compared the on-scene triage tool (SI, rSIG, and NEWS) and ED triage tool (Emergency Severity Index) parameters, massive transfusion protocol (MTP), and intensive care unit (ICU) admission with the area under ROC (univariable analysis) and diagnostic odds ratio (multivariable logistic regression analysis). The optimal cut-off threshold for the best parameter was determined by selecting the value that produced the highest area under the ROC curve. A total of 218 patients were traumatic patients transported by EMS to the ED, out of which 161 were classified as ESI levels 1-2, while the remaining 57 patients were categorized as levels 3-5 on the ESI triage scale. We found that NEWS was a more accurate triage tool to discriminate the severity of trauma patients than rSIG and SI. The area under the ROC was 0.74 (95% CI 0.70-0.79) (OR 18.98, 95% CI 1.06-337.25), 0.65 (95% CI 0.59-0.70) (OR 1.74, 95% CI 0.17-18.09) and 0.58 (95% CI 0.52-0.65) (OR 0.28, 95% CI 0.04-1.62), respectively (P-value <0.001). The cut point of NEWS to discriminate ESI levels 1-2 and levels 3-5 was >6 points. NEWS is the best on-scene triage screening tool to predict the severity at the emergency department, massive transfusion protocol (MTP), and intensive care unit (ICU) admission compared with other triage tools SI and rSIG.

Prognostic accuracy of emergency department triage tools for adults with suspected COVID-19: the PRIEST observational cohort study

BackgroundThe WHO and National Institute for Health and Care Excellence recommend various triage tools to assist decision-making for patients with suspected COVID-19. We aimed to compare the accuracy of triage...

Unenhanced computed tomography (CT) utility for triage at the emergency department during COVID-19 pandemic.

BackgroundUnenhanced chest computed tomography (CT) can assist in the diagnosis and classification of coronavirus disease 2019 (COVID-19), complementing to the reverse-transcription polymerase chain reaction (RT-PCR) tests; the performance of which has yet to be validated in emergency department (ED) setting. The study sought to evaluate the diagnostic performance of chest CT in the diagnosis and management of COVID-19 in ED.MethodsThis retrospective single-center study included 155 patients in ED who underwent both RT-PCR and chest CT for suspected COVID-19 from March 1st to April 1st, 2020. The clinical information, CT images and laboratory reports were reviewed and the performance of CT was assessed, using the RT-PCR as standard reference. Moreover, an adjudication committee retrospectively rated the probability of COVID-19 before and after the CT calculating the net reclassification improvement (NRI). Their final diagnosis was considered as reference. The proportion of patients with negative RT-PCR test that was directed to the referent hospital based on positive CT findings was also assessed.ResultsAmong 155 patients, 42% had positive RT-PCR results, and 46% had positive CT findings. Chest CT showed a sensitivity of 84.6%, a specificity of 80.0% and a diagnostic accuracy of 81.9% in suggesting COVID-19 with RT-PCR as reference. Concurrently, corresponding values of 89.4%, 84.3% and 86.5% were retrieved with the adjudication committee diagnosis as reference. For the subgroup of patients with age > 65, specificity and sensitivity were 50% and 80.8%, respectively. In patients with negative RT-PCR results, 20% (18/90) had positive chest CT finding and 22% (4/18) of those were eventually considered as COVID-19 positive according to the adjudication committee. After CT, the estimated probability of COVID-19 changed in 10/104 (11%) patients with available data: 4 (4%) were downgraded, 6 (6%) upgraded. The NRI was 1.92% (NRI event −2.08% + NRI non-event 5.36%). No patient with negative RT-PCR but positive CT was eventually directed to hospital.ConclusionChest CT showed promising sensitivity for diagnosing COVID-19 across all patients' subgroups. However, CT did not modify the estimated probability of COVID-19 infection in a substantial proportion of patients and its utility as an emergency department triage tool warrants further analyses.

Using clinical based vignettes to further develop a mass gathering event triage tool

BackgroundPreviously published triage tools for use at mass gathering events (MGE) lack real-world validation. Non-health care professionals, such as first aiders, first responders, and advanced responders often undertake a triage role at MGEs. This research aimed to determine consistency in the decision-making of a MGE triage tool. MethodVolunteer members of St John Ambulance Australia were recruited. Surveys included participant demographics and real-world clinical vignettes. Participants determined a triage category based on the vignettes and supplied triage tool. Demographics were analysed using descriptive statistics and responses to vignettes were analysed using Fleiss Kappa [p-bar]. ResultsThere were 110 participants, the majority male (60%), having completed a Bachelor or higher degree (53.6%), and were non-health care professionals (70%). Of the vignettes, there was a slightly better than moderate agreement (items: 18, p-bar: 0.55). There was an excellent level of agreeance for the resuscitation category (items: 3, b-par 0.69), and moderate level of agreeance for the urgent (items: 10, b-par 0.52) and minor (items: 5, b-par 0.52) categories. ConclusionsThis research demonstrated similar findings to that of emergency department triage tool validation. Multi-country, multi-site, multi-type, real-world testing at MGEs is the next step to progress the development of this tool.

Age is associated with increased mortality in the RETTS-A triage scale

BackgroundTriage is widely used in the emergency department (ED) in order to identify the patient’s level of urgency and often based on the patient’s chief complaint and vital signs. Age has been shown to be independently associated with short term mortality following an ED visit. However, the most commonly used ED triage tools do not include age as an independent core variable. The aim of this study was to investigate the relationship between age and 7- and 30-day mortality across the triage priority level groups according to Rapid Emergency Triage and Treatment System – Adult (RETTS-A), the most widely used triage tool in Sweden.MethodsIn this cohort, we included all adult patients visiting the ED at the Karolinska University Hospital, Sweden, from 1/1/2010 to 1/1/2015, n = 639,387. All patients were triaged according to the RETTS-A and subsequently separated into three age strata: 18–59, 60–79 and ≥ 80 years. Descriptive analyses and logistic regression was used. The primary outcome measures were 7- and 30-day mortality.ResultsWe observed that age was associated with both 7 and 30-day mortality in each triage priority level group. Mortality was higher in older patients across all triage priority levels but the association with age was stronger in the lowest triage group (p-value for interaction = < 0.001). Comparing patients ≥80 years with patients 18–59 years, older patients had a 16 and 7 fold higher risk for 7 day mortality in the lowest and highest triage priority groups, respectively. The corresponding numbers for 30-d mortality were a 21- and 8-foldincreased risk, respectively.ConclusionCompared to younger patients, patients above 60 years have an increased short term mortality across the RETTS-A triage priority level groups and this was most pronounced in the lowest triage level. The reason for our findings are unclear and data suggest a validation of RETTS-A in aged patients.

#Triage - Formal emergency department triage tools are inefficient, unfair, and they waste time and resources.

#Triage - Formal emergency department triage tools are inefficient, unfair, and they waste time and resources.

Reliability and validity of emergency department triage tools in low- and middle-income countries: a systematic review.

Despite the universal acknowledgment that triage is necessary to prioritize emergency care, there is no review that provides an overview of triage tools evaluated and utilized in resource-poor settings, such as low- and middle-income countries (LMICs). We seek to quantify and evaluate studies evaluating triage tools in LMICs. We performed a systematic review of the literature between 2000 and 2015 to identify studies that evaluated the reliability and validity of triage tools for adult emergency care in LMICs. Studies were then evaluated for the overall quality of evidence using the GRADE criteria. Eighteen studies were included in the review, evaluating six triage tools. Three of the 18 studies were in low-income countries and none were in rural hospitals. Two of the six tools had evaluations of reliability. Each tool positively predicted clinical outcomes, although the variety in resource environments limited ability to compare the predictive nature of any one tool. The South African Triage Scale had the highest quality of evidence. In comparison with high-income countries, the review showed fewer studies evaluating reliability and presented a higher number of studies with small sample sizes that decreased the overall quality of evidence. The quality of evidence supporting any single triage tool's validity and reliability in LMICs is moderate at best. Research on triage tool applicability in low-resource environments must be targeted to the actual clinical environment where the tool will be utilized, and must include low-income countries and rural, primary care settings.

Using a simplified pre-hospital 'MET' score to predict in-hospital care and outcomes.

Medical emergency team (MET) activation criteria serve as a predictor of serious adverse events on hospital wards and in the emergency department (ED). We aimed to determine whether in-hospital MET activation criteria would be useful in identifying patients at risk in pre-hospital care. The data were collected retrospectively from 610 adult patients treated by physician-staffed helicopter emergency medical services. Pre-hospital vital signs were compared with MET activation criteria and scored accordingly to receive a simplified pre-hospital 'MET' score. The primary outcome measure was hospital mortality. The secondary outcome measures were admission to intensive care unit and the length of ED stay, intensive care unit (ICU) stay and hospital stay. The simplified pre-hospital 'MET' score was also compared with Emergency Severity Index (ESI) used as a triage tool in ED. Higher simplified pre-hospital 'MET' scores were associated with hospital mortality (P<0.001), the need for ICU treatment (P<0.001) and a more urgent ESI class in the ED (P<0.001). Higher simplified pre-hospital 'MET' scores were associated with shorter stay in the ED (P<0.001), longer stay in the ICU (P<0.001) and longer hospital stay (P<0.001). A simplified pre-hospital 'MET' score was an independent predictor for hospital mortality (odds ratio 2.42, confidence interval 1.84 3.18, P<0.001), regardless of age or patient's previous overall physical health classified by American Society of Anesthesiologists physical status classification system. A simplified pre-hospital 'MET' score is a predictor for patient outcome and could serve as a risk assessment tool for the health care provider on-scene.

Children who harm themselves: development of a paediatric emergency department triage tool

Introduction:Children who harm, hurt or kill themselves are a significant issue for health professionals in emergency departments (ED), with over 60 000 young people presenting to ED in the UK...

Development of an Emergency Department Triage Tool to Predict Acidosis Among Children With Gastroenteritis

Design a triage assessment tool that predicts acidosis in children with vomiting, diarrhea, and dehydration. A convenience sample of patients aged 3 months to 7 years with vomiting and/or diarrhea were enrolled in the triage area of a pediatric hospital's emergency department (ED). Caretakers of the eligible children completed a parental questionnaire assessing the patient's history of presenting illness. The triage nurse completed a 4-point physical examination assessment form. Collected information from the parental questionnaire and examination findings from the nurses' assessment were analyzed for factors that predicted acidosis in patients which was defined as having a serum bicarbonate level of 16 mmol/L or less or, if unavailable, an end-tidal carbon dioxide of 31 mm Hg or less. One hundred eighteen of the 130 patients enrolled had either a documented serum bicarbonate level or an end-tidal carbon dioxide and were therefore used in the final analysis for the primary outcome. Twenty-nine patients (25%) had acidosis. Univariate predictors of acidosis were younger age (mean [SD], 1.7 [1.4] vs. 3.1 [2.2] years, P = 0.002), previous evaluation by the primary care physician (62% vs. 33%, P = 0.008), being sent in by the primary care physician (66% vs. 33%, P = 0.002), and a worse overall appearance based on the triage nurse's mark on a 0-cm ("alert/playful") to 10-cm ("lethargic/limp") visual analog scale (3.7 [2.8] vs. 2.4 [2.2] cm, P = 0.013). A regression tree analysis identified age younger than 2 years, dry mucous membranes, and duration of illness more than 2 days as sequential factors predictive of patients at risk for acidosis. This decision tree identified patients with acidosis with an 89.7% sensitivity (95% confidence interval, 71.5%-97.3%) and a 93.6% negative predictive value (95% confidence interval, 81.4%-98.3%). The stepwise regression tree triage assessment tool dichotomizing patients based on age younger than 2 years, dry mucous membranes, and days of illness more than 2 days was able to predict acidosis with 90% sensitivity in patients presenting to the ED for evaluation of gastroenteritis. Identifying patients with acidosis early in their ED course allows the treating ED physician to focus more attention and resources toward rehydrating this at-risk population of patients with gastroenteritis.

Implementation of the Victorian Emergency Department Mental Health Triage Tool

Summary In 2005, the Department of Human Services (Victoria) commissioned the National Institute of Clinical Studies (NICS) to develop and implement a statewide emergency department triage tool to improve the ED triage processes for mental health presentations to Victorian Emergency Departments. The project was undertaken over a 7-month period from September 2005 to March 2006. This paper describes the implementation approach undertaken by NICS and the outcomes of the project.