Emergency Severity Index Research Articles

Evaluation of changes in pediatric emergency department utilization during COVID-19 pandemic

BackgroundDuring the coronavirus disease 2019 (COVID-19) pandemic period, the use of emergency services with pediatric non-COVID patients has decreased considerably. We aimed to examine whether there was a change in the demographic data, triage profile, causes, management, and cost of pediatric emergency department (PED) visits of non-COVID patients during the pandemic period. MethodsThis study was a retrospective, single-center, observational comparative study that was conducted at the PED. Patient records were examined during “the pandemic spring” and the same period of the previous year. Patient demographics, waiting time, and outcome of the PED visit were analyzed in the entire population of children admitted to the PED during the study period, whereas more precise data such as the reason for PED use, duration of symptoms, urgency levels according to the Emergency Severity Index (ESI), final diagnosis, management, and cost of patient care were analyzed in a sample of admitted patients. We used the chi-square test, Fisher's exact test, and Mann–Whitney U test for statistical analyses. ResultsA total of 62,593 PED visits occurred. During the pandemic period, PED visits showed a decrease of 55.8% compared to the previous year. Patients included in the sampling study group were selected using a systematic random sampling method. The median waiting time during the pandemic period was significantly shorter than the previous year (median 14 min [IQR: 5–32] vs. median 5 min [IQR: 2–16]; p<0.001). The median duration of symptoms was 1 day (1–2) in both groups. Emergency Severity Index (ESI) levels I, II, and III showed a significant increase (27.7% vs. 37.3%) in triage scoring compared to levels IV and V (72.3% vs. 62.7%) during the pandemic period (p<0.001). The median cost per patient during the pandemic period was statistically higher compared to the previous year ($19.57 [19.57–40.50] vs. $25.34 [31.50–52.01]; p<0.001). Overall costs during the pandemic period had a 1.6-fold decline. ConclusionWe highlighted the changes in an ordinary PED profile during an extraordinary period. A shift in ESI levels in a more emergent direction was observed. While the number of nonurgent patients, especially those with infections, decreased, the rates of surgical cases, acute neurological and heart diseases, home accidents, and poisoning increased relative to the pre-pandemic period.

30 Characteristics of Patients Restrained in the Emergency Department and Evaluation for Disparities in Care

Physical restraints are occasionally used in the emergency department (ED) to manage acute agitation to prevent self-harm and to protect staff, with a reported frequency of 0.5-1.4%. There is limited information comparing the demographic factors associated with the use of restraints for behavioral versus medical indications. Prior studies have also identified an association between socioeconomic and demographic factors and the use physical restraints, raising concern for the presence of implicit bias. The objective of this study was to identify the socioeconomic and demographic characteristics of patients placed in physical restraints for behavioral versus medical indications and to assess the variables that may increase the risk of patients being placed in restraints specifically for behavior indications. A cross sectional study of adult ED patients at a Level 1 Trauma tertiary academic medical center during March 2019 through February 2021 was performed to identify patients placed in physical restraints for medical or behavioral indications. Comparisons between behavioral and medical restraint groups were assessed using the t- test (for age) and the Fisher exact test (for sex, race, ethnicity, emergency severity index (ESI), insurance status, time of arrival, age over 50, psychiatric admission, and medical admission). Factors associated with behavioral restraint use compared to medical restraint use were assessed by a multivariable logistic regression analysis. Odds ratio (OR) and their 95% confidence intervals were reported. A two-sided 0.05 significance level was used throughout. SAS versions 9.4 (SAS Institute, Cary, North Carolina) software was utilized for statistical analysis. Among the 172, 708 ED visits during the study period, 1, 165 (0.67%) involved the use of restraints. Behavioral restraints were applied in 612 patients (53.5%) and medical restraints in 553 (47.5%). Overall physical restraint use was similar between white and non-white patients (0.74% and 0.71% respectively, Fisher Exact OR 1.04, p=0.55). However, significant differences were found among age, sex, race, ESI, insurance status, psychiatric and medically hospitalized patients in further analysis between the behavioral and medical restraint groups (p<0.0001). Factors that were identified as significantly increasing the risk of receiving behavioral restraints in particular included male sex, insurance and race; the c-statistics for the logistic model was 0.864. The demographic and socioeconomic characteristics of patients placed in restraints for medical indications are different than those placed in restraints for behavioral indications. Although race was identified as a factor increasing the risk for behavioral restraints use in the ED, the overall use of physical restraints was similar in white versus non-white patients suggesting against the presence of implicit bias against non-white patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

COVID-19 vaccine hesitancy among patients in two urban emergency departments.

BackgroundWidespread vaccination is an essential component of the public health response to the COVID‐19 pandemic, yet vaccine hesitancy remains pervasive. This prospective survey investigation aimed to measure the prevalence of vaccine hesitancy in a patient cohort at two urban emergency departments (EDs) and characterize underlying factors contributing to hesitancy.MethodsAdult ED patients with stable clinical status (Emergency Severity Index 3–5) and without active COVID‐19 disease or altered mental status were considered for participation. Demographic elements were collected as well as reported barriers/concerns related to vaccination and trusted sources of health information. Data were collected in person via a survey instrument proctored by trained research assistants.ResultsA total of 1,555 patients were approached, and 1,068 patients completed surveys (completion rate = 68.7%). Mean (±SD) age was 44.1 (±15.5) years (range = 18–93 years), 61% were female, and 70% were Black. A total of 31.6% of ED patients reported vaccine hesitancy. Of note, 19.7% of the hesitant cohort were health care workers. In multivariable regression analysis, Black race (odds ratio [OR] = 4.24, 95% confidence interval [CI] = 2.62 to 6.85) and younger age (age 18–24 years—OR = 4.57, 95% CI = 2.66 to 7.86; age 25–35 years—OR = 5.71, 95% CI = 3.71 to 8.81) were independently associated with hesitancy, to a greater degree than level of education (high school education or less—OR = 2.27, 95% CI = 1.23 to 4.19). Hesitant patients were significantly less likely to trust governmental sources of vaccine information than nonhesitant patients (39.6% vs. 78.9%, p < 0.001); less difference was noted in the domain of trust toward friends/family (51.1% vs. 61.0%, p = 0.004). Hesitant patients also reported perceived vaccine safety concerns and perceived insufficient research.ConclusionsVaccine hesitancy is common among ED patients and more common among Black and younger patients, independent of education level. Hesitant patients report perceived safety concerns and low trust in government information sources but less so friends or family. This suggests that strategies to combat hesitancy may need tailoring to specific populations.

335 Emergency Severity Index Triage Equivalency to Sort Assess Life Saving Interventions Treatment and Transport Disaster Triage

Disaster triage methodologies in the field are relatively established, but there is less guidance for first receivers and emergency departments (ED) once patients arrive. The relationship between general operational triage methodology, such as the Emergency Severity Index (ESI), and disaster-based triage, such as Sort Assess Life Saving Interventions Treatment And Transport Disaster Triage (SALT), is of immediate practical importance for an ED experiencing a disaster situation. The ability to quickly convert triage classifications from ESI to SALT could conserve precious time and resources already at a premium.

46 External Validation of a Singapore Electronic Health Record-Based Emergency Department Admission Prediction Model in a North American Setting

Models for predicting admission of patients from an emergency department (ED) have been suggested as a device for reducing ED crowding; however, such models are not widely implemented. The objective of this study is to validate an existing ED admission model on data from an outside hospital, as a first step to identifying a generalizable means to develop such models. Previously, an ED admission model was developed on retrospective observational data at a large urban hospital in Singapore. Data from the electronic health record (EHR) of a tertiary medical center in Durham, North Carolina (NC ED) were curated and transformed to align closely with the features of the Singapore model. A stepwise logistic regression model was built on these features to predict the probability of inpatient admission for patients presenting to the NC ED at the time of triage. A randomly selected 30% subset of the data was withheld from training and used to validate the model. Performance metrics were compared to those attained by the Singapore team. A total of 60, 064 encounters from January to December 2019 were included in the analysis; these patients had an admission rate of 28.2%. Variables used for modeling were first identified by the Singapore team and included age, sex, day of week, Emergency Severity Index (ESI), race, shift time, mode of arrival, time of year, postal code, fever status, and number of prior ED visits. The model we trained on the NC ED EHR data, using the features of the Singapore team’s model, had an area under the ROC curve (AUROC) of 0.821 (95% CI, 0.804-0.837), comparable to the AUROC of 0.825 (95% CI, 0.824-0.827) obtained by the Singapore team’s on their data. The most significant features associated with discharge included an ESI Score above 3 and ED arrival by law enforcement; the most significant features associated with admission included ESI Score below 3, fever status, and advanced age. We have been able to map elements from the NC ED EHR to the Singapore triage model elements to develop a model that performs comparably. Thus, a general method for building simple, effective ED admission models at various independent hospitals is attainable and scalable.

Comparative Analysis Of Triage Systems At Emergency Departments Of Different Countries: Implementation In Kazakhstan

Medical sorting is aimed at assessment of disease severity and has to be carried out within a short time to determine the priorities for patient care and transportation to the most appropriate place for future treatment. The goal of this study was to provide an integrative review by analyzing the publications on the most common triage systems worldwide in order to select and implement the most reliable system at emergency departments. We searched for publications relevant to our comparative analysis in evidence-based medicine databases. A total of 1,740 literary sources were identified, of which 42 were selected for analysis. Comparative analysis of different triage systems may help implementing the most efficient system in Kazakhstan. The Emergency Severity Index is considered the most reliable and accurate tool used in international practice, and it could provide a basis for introduction of triage system at emergency departments in Kazakhstan.

Prediction of hospitalization using artificial intelligence for urgent patients in the emergency department

Timely assessment to accurately prioritize patients is crucial for emergency department (ED) management. Urgent (i.e., level-3, on a 5-level emergency severity index system) patients have become a challenge since under-triage and over-triage often occur. This study was aimed to develop a computational model by artificial intelligence (AI) methodologies to accurately predict urgent patient outcomes using data that are readily available in most ED triage systems. We retrospectively collected data from the ED of a tertiary teaching hospital between January 1, 2015 and December 31, 2019. Eleven variables were used for data analysis and prediction model building, including 1 response, 2 demographic, and 8 clinical variables. A model to predict hospital admission was developed using neural networks and machine learning methodologies. A total of 282,971 samples of urgent (level-3) visits were included in the analysis. Our model achieved a validation area under the curve (AUC) of 0.8004 (95% CI 0.7963–0.8045). The optimal cutoff value identified by Youden's index for determining hospital admission was 0.5517. Using this cutoff value, the sensitivity was 0.6721 (95% CI 0.6624–0.6818), and the specificity was 0.7814 (95% CI 0.7777–0.7851), with a positive predictive value of 0.3660 (95% CI 0.3586–0.3733) and a negative predictive value of 0.9270 (95% CI 0.9244–0.9295). Subgroup analysis revealed that this model performed better in the nontraumatic adult subgroup and achieved a validation AUC of 0.8166 (95% CI 0.8199–0.8212). Our AI model accurately assessed the need for hospitalization for urgent patients, which constituted nearly 70% of ED visits. This model demonstrates the potential for streamlining ED operations using a very limited number of variables that are readily available in most ED triage systems. Subgroup analysis is an important topic for future investigation.

Disparities in Pediatric Emergency Department Length of Stay and Utilization Associated With Primary Language.

The aim of the study was to investigate the association between primary language and length of stay (LOS) in the pediatric emergency department (ED) within the context of known disparities impacting healthcare experiences and outcomes for patients with language barriers. We conducted a retrospective cohort study of consecutive encounters of patients presenting to, and discharged from, an urban pediatric ED from May 2015 through April 2018. Encounters were grouped into English primary language (EPL), Spanish (SPL), and other (OPL). Mean LOS comparisons were stratified by Emergency Severity Index (ESI). Bivariate and multivariate analyses were used to examine the relationship between LOS and variables, including age, sex, race/ethnicity, insurance, and time of presentation. A total of 139,163 encounters were included. A higher proportion of SPL and OPL encounters were characterized as lower ESI acuity compared with EPL. Significantly longer LOS for SPL and OPL encounters was observed in the 2 lower acuity strata. The ESI 4-5 stratum demonstrated the greatest LOS disparity between EPL, SPL, and OPL (94 vs 103 vs 103 minutes, respectively, P < 0.001). In the highest acuity stratum, ESI 1-2, there was a nonsignificant trend toward longer LOS among EPL encounters (P = 0.08). The multivariate model accounted for 24% of LOS variance, but effect sizes were small for all variables except for ESI and age. Patients with Spanish or other non-EPL who were triaged to lower acuity ESI levels experienced longer LOS in the pediatric ED than English-speaking counterparts. They also used the ED more frequently for low acuity issues, possibly reflecting disparities in access to primary care.

A Quality Initiative to Decrease Time Until Analgesic for Fracture-associated Pain in the Pediatric Emergency Department.

Introduction:Long bone fractures are a common cause of pain in the pediatric emergency department (PED), and ensuring timely delivery of analgesic medications is essential for these children. We aimed to decrease the median time to the first dose of analgesic for long bone fracture–associated pain in our PED to 36 minutes or less by July 1, 2015.Methods:A series of 4 initiatives were implemented in successive “plan, do, study, act” rapid cycles. Initiatives consisted of educational interventions for staff regarding Emergency Severity Index procedures for triaging pain, transition to in-room triage, enhanced communication about quality goals using a “quality board,” and ongoing staff educational sessions on outlier cases as well as biases and barriers to quality.Results:We implemented the initiatives from April through July of 2015. The monthly median time to analgesic delivery for long bone fracture–associated pain in the PED decreased from 72 minutes in April to 33.5 minutes in July of 2015. For 12 months following the first intervention, the average monthly median time to the first analgesic dose was 48.5 versus 66.3 minutes for the prior 12 months.Conclusions:A series of 4 interventions led to a decrease in the median time to the first dose of analgesic for long bone fracture–associated pain in the PED.

It's Time to Provide Evidence-Based Care to Individuals with Sickle Cell Disease: A Call to Action

In the current issue of the Journal of Emergency Nursing, Linton et al1 report on their successful implementation of a clinical support tool (a banner to recommend emergency severity index [ESI] triage level 2) to improve the care of sickle cell disease (SCD) for individuals presenting to the emergency department with severe pain referred to as vaso-occlusive crisis (VOC). The researchers and clinical team are to be commended. The correct assignment of a high priority triage level is evidence-based and important to facilitate rapid placement in a treatment area to expedite pain management.

Prevalence and Factors Associated with Attendance of Non-Urgent Cases of Pediatric Emergency Room in Riyadh, Saudi Arabia

The care for emergency conditions is an important feature of developed the systems of healthcare. Emergency medicine is the medical specialty dedicated to diagnosis and treatment of unforeseen illness or injuries. Overcrowding of Emergency Room (ER) by non-urgent cases is a problem that should be raised and reasons for that need to be sought. The aim is to identify the prevalence and factors behind non-urgent cases attending to acute care in Riyadh. This is a cross-sectional study which was conducted over a one-year period. Questionnaires were distributed to parents of children ≤14 years attending pediatric emergency room (ER) in multiple hospitals in Riyadh, Saudi Arabia. The sample size was 383 participants recruited using convenience sampling technique. The inclusion criteria comprised of pediatrics ≤14 years attending to ER with urgent cases (level 1, 2 and 3 according to Emergency Severity Index) and minor trauma (contusion, abrasion), sore throat, upper respiratory tract infection (URTI), mild abdominal pain, vomiting alone or diarrhea alone with no sign of dehydration of (level 4 and 5 according to Emergency Severity Index). 383 questionnaires were collected. The sample consisted mostly of females 56%. Upper respiratory tract infection (URTI) was the highest reason for pediatric emergency room visits (55.1%). Only 12.2% have visited primary health care (PHC) prior to emergency room. Most of participants have sources for medical advice other than emergency physicians (80.3%). Results also show that many parents who have brought their kids to emergency lacked the knowledge that their cases could be managed in primary health care (76.2%). In Conclusion, results have shown that many parents choose ER whenever their children have any symptoms. Reasons for that varied between each participant. Many participants are ignorant of the capabilities of PHC centers, and their services. Raising awareness regarding primary health should be the objective to reduce number of non-urgent cases visiting emergency room.

Changes in Emergency Department Volumes at the Largest U.S. Military Hospital During the COVID-19 Pandemic.

The coronavirus-2019 (COVID-19) pandemic has significantly impacted global healthcare delivery. Brooke Army Medical Center (BAMC) is the DoD's largest hospital and a critical platform for maintaining a ready medical force. We compare temporal trends in patient volumes and characteristics in the BAMC emergency department (ED) before versus during the pandemic. We abstracted data on patient visits from the BAMC ED electronic medical record system. Data included patient demographics, visit dates, emergency severity index triage level, and disposition. We visually compared the data from January 1, 2019 to November 30, 2019 versus January 1, 2020 to November 30, 2020 to assess the period with the most apparent differences. We then used descriptive statistics to characterize the pre-pandemic control period (1 March-November 30, 2019) versus the pandemic period (1 March-November 30, 2020). Overall, when comparing the pre-pandemic and pandemic periods, the median number of visits per day was 232 (Interquartile Range (IQR) 214-250, range 145-293) versus 165 (144-193, range 89-308, P < .0001). Specific to pediatric visits, we found the median number of visits per day was 39 (IQR 33-46, range 15-72) versus 18 (IQR 14-22, range 5-61, P < .001). When comparing the median number of visits by month, the volumes were lower during the pandemic for all months, all of which were strongly significant (P < .001 for all). The BAMC ED experienced a significant decrease in patient volume during the COVID-19 pandemic starting in March 2020. This may have significant implications for the capacity of this facility to maintain a medically ready force.

Developing machine learning models to personalize care levels among emergency room patients for hospital admission.

ObjectiveTo develop prediction models for intensive care unit (ICU) vs non-ICU level-of-care need within 24 hours of inpatient admission for emergency department (ED) patients using electronic health record data.Materials and MethodsUsing records of 41 654 ED visits to a tertiary academic center from 2015 to 2019, we tested 4 algorithms—feed-forward neural networks, regularized regression, random forests, and gradient-boosted trees—to predict ICU vs non-ICU level-of-care within 24 hours and at the 24th hour following admission. Simple-feature models included patient demographics, Emergency Severity Index (ESI), and vital sign summary. Complex-feature models added all vital signs, lab results, and counts of diagnosis, imaging, procedures, medications, and lab orders.ResultsThe best-performing model, a gradient-boosted tree using a full feature set, achieved an AUROC of 0.88 (95%CI: 0.87–0.89) and AUPRC of 0.65 (95%CI: 0.63–0.68) for predicting ICU care need within 24 hours of admission. The logistic regression model using ESI achieved an AUROC of 0.67 (95%CI: 0.65–0.70) and AUPRC of 0.37 (95%CI: 0.35–0.40). Using a discrimination threshold, such as 0.6, the positive predictive value, negative predictive value, sensitivity, and specificity were 85%, 89%, 30%, and 99%, respectively. Vital signs were the most important predictors.Discussion and ConclusionsUndertriaging admitted ED patients who subsequently require ICU care is common and associated with poorer outcomes. Machine learning models using readily available electronic health record data predict subsequent need for ICU admission with good discrimination, substantially better than the benchmarking ESI system. The results could be used in a multitiered clinical decision-support system to improve ED triage.

80 Association Of COVID-19 “Safer-At-Home” Orders With ED-To-ED Interfacility Transfers

Study Objectives: With the reduction in ED volumes during the COVID-19 pandemic, we sought to examine the association of “Safer at Home” lockdown orders with ED-to-ED interfacility transfers. Methods: We conducted a retrospective observational analysis using hospital electronic administrative data of all interfacility ED-to-ED transfers to a single, quaternary care adult ED from January 1, 2018 to September 30, 2020 in Middle, Tennessee. “Safer at Home” orders were issued March 23, 2020 in Davidson County, TN in response to the COVID-19 pandemic mandating citizens stay inside their homes unless engaged in “essential activities.” We defined the post-lockdown period as March 23, 2020 to September 30, 2020. We sought to identify transfers that may not require in-person evaluation and may be amenable to other modalities (eg, telehealth). Called “potentially avoidable transfers,” (PATs), they are defined as ED-to-ED interfacility transfers discharged from the ED or admitted to the hospital for <24 hours without a procedure. To operationalize this definition, we constructed a multivariable logistic regression model to examine whether this lockdown order was associated with higher odds of a transfer being a PAT. We adjusted for seasonality, time since start of the study, patient demographics including age (per 10 years), sex, race, arrival emergency severity index triage acuity, mode of arrival (helicopter vs. ground), timing of arrival (ie, business hours), clinical condition using AHRQ’s clinician condition software (CCS), and rurality. Results: During the study period there were 20,978 ED-to-ED transfers meeting eligibility criteria and, of those, 4,806 (23%) met PAT criteria. In the 7 months post-lockdown PATs were generally down trending when compared month-to-month across years. The first month post-lockdown saw a decrease in transfers and PATs (17% and 28%, respectively) but this was not sustained. In the multivariable model, there was a significant seasonal effect. After adjusting for seasonality, the lockdown was not associated with PATs (adjusted odds ratio [aOR] 0.99, 95% CI 0.2, 5.2). The following were associated with increased odds of being a PAT: lack of insurance and arrival during non-business hours. The following were less likely to be PATs: female sex, increasing age, specific diagnostic categories (digestive, infectious, and circulatory conditions), and arrival by nonambulance. Conclusions: In this single center study, there was no effect of the COVID-19 lockdown orders on PATs. However, after adjusting for covariates and seasonality, we did identify a considerable seasonal effect and an overall downward trend in PATs over time. These findings do not address the appropriateness of the transfer but whether in-person evaluation may be amenable to telehealth or other potential means. Generalizability of this single center study should be examined in other settings along with reasons for the potential downward trend.

Impact of COVID-19 on presentation, management, and outcomes of acute care surgery for gallbladder disease and acute appendicitis.

BACKGROUNDThe ongoing coronavirus disease 2019 (COVID-19) pandemic has significantly disrupted both elective and acute medical care. Data from the early months suggest that acute care patient populations deferred presenting to the emergency department (ED), portending more severe disease at the time of presentation. Additionally, care for this patient population trended towards initial non-operative management.AIMTo examine the presentation, management, and outcomes of patients who developed gallbladder disease or appendicitis during the pandemic.METHODSA retrospective chart review of patients diagnosed with acute cholecystitis, symptomatic cholelithiasis, or appendicitis in two EDs affiliated with a single tertiary academic medical center in Northern California between March and June, 2020 and in the same months of 2019. Patients were selected through a research repository using international classification of diseases (ICD)-9 and ICD-10 codes. Across both years, 313 patients were identified with either type of gallbladder disease, while 361 patients were identified with acute appendicitis. The primary outcome was overall incidence of disease. Secondary outcomes included presentation, management, complications, and 30-d re-presentation rates. Relationships between different variables were explored using Pearson’s r correlation coefficient. Variables were compared using the Welch’s t-Test, Chi-squared tests, and Fisher’s exact test as appropriate.RESULTSPatients with gallbladder disease and appendicitis both had more severe presentations in 2020. With respect to gallbladder disease, more patients in the COVID-19 cohort presented with acute cholecystitis compared to the control cohort [50% (80) vs 35% (53); P = 0.01]. Patients also presented with more severe cholecystitis in 2020 as indicated by higher mean Tokyo Criteria Scores [mean (SD) 1.39 (0.56) vs 1.16 (0.44); P = 0.02]. With respect to appendicitis, more patients were diagnosed with a perforated appendix at presentation in 2020 [20% (36) vs 16% (29); P = 0.02] and a greater percentage were classified as emergent cases using the emergency severity index [63% (112) vs 13% (23); P < 0.001]. While a greater percentage of patients were admitted to the hospital for gallbladder disease in 2020 [65% (104) vs 50% (76); P = 0.02], no significant differences were observed in hospital admissions for patients with appendicitis. No significant differences were observed in length of hospital stay or operative rate for either group. However, for patients with appendicitis, 30-d re-presentation rates were significantly higher in 2020 [13% (23) vs 4% (8); P = 0.01].CONCLUSIONDuring the COVID-19 pandemic, patients presented with more severe gallbladder disease and appendicitis. These findings suggest that the pandemic has affected patients with acute surgical conditions.

System Level Informatics to Improve Triage Practices for Sickle Cell Disease Vaso-Occlusive Crisis: A Cluster Randomized Controlled Trial

BackgroundNational Heart Lung and Blood Institute guidelines for the treatment of vaso-occlusive crisis among people with sickle cell disease in the emergency department recommend assigning an emergency severity index of 2 at triage. However, patients with sickle cell disease often do not receive guideline-concordant care at triage. To address this gap, a decision support tool was developed, in the form of a text banner on the triage page in the electronic health record system, visible to triage nurses. MethodsA prospective quality improvement initiative was designed where the emergency severity index clinical decision support tool was deployed to a stratified random sample of emergency department triage nurses to receive the banner (n = 24) or not to receive the banner (n = 27), reminding them to assign the patient to emergency severity index category 2. The acceptability of the emergency severity index clinical decision support tool was evaluated with the Ottawa Acceptability of Decision Rules Instrument. Descriptive and bivariate (chi-square test) statistics were used to characterize the study's primary outcome, proportion of visits assigned an emergency severity index of 2 or higher. A generalized linear mixed model with clustering at the level of the triage nurse was performed to test the association between the banner intervention and triage practices. ResultsA total of 384 ED visits were included for analysis. Before study initiation, the percentage of sickle cell disease patients’ visits with the proper emergency severity index assignment at triage was 37.04%. After initiation, the proportion of sickle cell disease patients’ visits with an emergency severity index of 2 or higher triaged by nurses in the intervention group was markedly higher in the intervention group than in the control group (64.95% vs 35.05%; χ2 = 8.79, P ≤ .003). Accounting for clustering by nurse, the odds ratio for proper triage emergency severity index assignment was 3.22 (95% confidence interval 1.17–8.85; P ≤ .02) for the intervention versus control. Surveyed triage nurses reported the emergency severity index clinical decision support tool to be moderately acceptable (nurses’ mean Ottawa Acceptability of Decision Rules Instrument scores ranged from 4.13 to 4.90 on the 6-point scale; n = 11). There were no differences in ED experience outcomes including time to first analgesic or length of stay between the control and intervention groups. ConclusionSubstantial improvements in triage guideline concordance were achieved and sustained without direct nursing education.

Analysis of pediatric emergency department patient volume trends during the COVID-19 pandemic.

During the early period of the COVID-19 pandemic there was a substantial decrease in pediatric emergency department (PED) visitation. The intent of this study is to report PED utilization during the COVID-19 pandemic in an urban pediatric referral center located close to the epicenter in the northeastern US.A retrospective analysis of medical records of patients visiting the PED at Robert Wood Johnson University Hospital (RWJUH) was performed. Data included: daily census, admission rate, Emergency Severity Index, and ICD-10 diagnosis codes for the period of February through July, 2018 to 2020.By the week of March 26th, visits had decreased by 70% compared to the average of the previous 2 years. This census nadir lasted for 6 weeks. At 5 weeks postnadir the average daily census recovered to levels 40% lower than prior year norms and remained at that level during subsequent months. The greatest decreases were seen in low-acuity visits. Visits for behavioral health and fractures decreased by approximately 50% and 70%, respectively, but recovered to prior year norms by June and July of 2020. Visits for asthma exacerbation decreased by as much as 87% and remained at record lows for the remainder of the study period.A substantial and persistent decrease in PED visitation was experienced during the COVID-19 pandemic. Whereas visits for behavioral health and fractures have recovered to prior year norms, visits for asthma exacerbation remain at record lows. Further research is needed to ascertain the causes of these changes, including patient perceptions of the PED.

The Undertriage of Older Adults in the Emergency Department: A Review of Interventions.

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse and the emergency nurse and to assist with the translation of research into practice. A topic and a research study are selected for each column. A patient scenario is presented as a vehicle, in which to review and critique, the findings of the selected research study. In this column, we review the conclusions of A. Malinovska, L. Pitasch, N. Geigy, C. H. Nickel, and R. Bingisser (2019) from their article, titled "Modification of the Emergency Severity Index Improves Mortality Prediction in Older Patients."

Assessment of patient mobility improves the risk stratification of triage with the Emergency Severity Index: a prospective cohort study.

Formal triage may assign a low acuity to patients at high risk of deterioration and mortality. A patient's mobility can be easily assessed at triage. To investigate if a simple assessment of mobility at triage can improve the Emergency Severity Index's (ESI) prediction of adverse outcomes. Prospective observational study of all patients attending the emergency department (ED) of a single academic hospital in Switzerland over a period of 3 weeks. Triage clinicians classified participants as having normal or impaired mobility at triage. Impaired mobility was defined as the lack of a stable independent gait, regardless of its cause or duration (e.g. any patient who needed help to walk). The primary outcome was 30-day mortality. We performed a survival analysis stratified by mobility and ESI level. We compared the performance of regression models including the ESI alone or in combination with mobility as predictors of mortality using the Bayesian information criterion (BIC). 2523 patients were included in the study and 880 (34.9%) had impaired mobility. Patients with impaired mobility had a lower median 30-day survival in ESI levels 1-3. Survival of patients with normal mobility was similar regardless of their ESI level. The assessment of mobility at triage improves the ESI algorithm's risk stratification.

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study.

PurposePatients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC).MethodsA retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods.ResultsDuring the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5).ConclusionsThis model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.