Triage Acuity Research Articles

Emergency Department Quality of Care for Sickle Cell Disease in Ontario, Canada: A Population-Based Matched Cohort Study

Background: Acute vaso-occlusive crisis (VOC) in sickle cell disease (SCD) frequently leads patients to seek emergency department (ED) care. Whether or not health inequities exist, and their exact nature, is poorly understood in ED visits for SCD VOC within a universal publicly funded healthcare system. In this study, we aimed to address this knowledge gap by characterizing the landscape of ED care burden and quality indicators for SCD VOC management in the province of Ontario, Canada. Methods: We used population-level health administrative data to identify patients with SCD in Ontario who presented to the ED with SCD VOC (ICD-10-CA code D57.0) from 2006 to 2018. We evaluated quality of care indicators in the ED for this population and compared these with a general population group matched by age, sex, neighbourhood income quintile, geography (forward sortation area) and date of ED visit (-15 to +15 days per visit) (35,370 ED visits; 27,195 patients). Results: We identified 1,811 patients who presented to the ED with SCD VOC for a total of 13,123 ED visits over the study period. Of ED presentations, 40% were pediatric (< 18 years), 47% were male and 99% lived in urban settings. Compared to ED visits for the matched group, ED visits for SCD VOC had a significantly higher proportion of high acuity triage scores (CTAS 1 or 2) (74% vs 18%; p < 0.001), shorter time to initial physician assessment (76 ± 82 vs 90 ± 86 minutes; mean ± SD, p < 0.001), longer period of ED assessment and observation (432 ± 261 vs 212 ± 179 minutes; p < 0.001), increased likelihood of hospital admission (62% vs 5%; p < 0.001), longer duration of inpatient stay (5.2 ± 6.7 vs 4.0 ± 8.1 days; p < 0.001), and higher rates of repeat ED visits within 30 days of ED discharge (0.57 ± 1.44 vs 0.26 ± 0.79 visits; p < 0.001). We found specific socio-demographic variables associated with a poorer quality of care in ED visits for SCD VOC, including patients who were adults, male, from a low-income neighbourhood, having a greater number of dependents, a higher neighbourhood level of material deprivation, from an ethnically-concentrated neighbourhood, and those who lived in a residentially unstable region. Bivariate analyses for clinically meaningful outcomes (defined as ED disposition, repeat ED visit within 30 days, length of hospital admission stay, and being among the highest user bracket of ED care) further revealed significant socio-demographic associations that validated the clinical relevance of these determinants underlying ED metric disparities found within the SCD cohort (Table 1). In subgroup comparisons, we observed a significant difference in triage acuity scoring for adults compared with children with SCD VOC, with a 25% lower rate of high acuity triage score (CTAS 1 or 2) (66% vs 86%). We also found that despite a majority of adults with SCD VOC receiving these scores compared to those in the matched group (66% vs 18%), their mean times to initial physician assessment were not significantly different (90 ± 94 vs 91 ± 89 minutes), reflecting an average SCD VOC wait time longer than the clinical practice guideline recommendation of first dose analgesic within the first 60 minutes of ED arrival. Furthermore, we identified a negative correlation between poor ED metrics and patients with SCD who were highly dependent on ED care (defined as 4-9 or ≥ 10 ED visits for SCD VOC per year) at levels significantly above the matched comparative baseline. Conclusions: Indicators of ED care for SCD largely reflect the clinical acuity and severity of VOC presentations in Ontario, Canada. However, significant disparities in the quality of care received and in clinical outcomes for specific subgroups of patients with SCD, including those most vulnerable within this patient population, raises concern from a health equity perspective.By leveraging this landscape of SCD ED care, future policy, clinical and research efforts must work to understand, address and close these gaps in order to achieve best and equitable care for all. Disclosures No relevant conflicts of interest to declare.

Prevalence of Cigarette Smoking Among Adult Emergency Department Patients in Canada.

IntroductionTobacco smoking is a priority public health concern, and a leading cause of death and disability globally. While the daily smoking prevalence in Canada is approximately 9.7%, the proportion of smokers among emergency department (ED) patients has been found to be significantly higher. The purpose of this survey study was to determine the smoking prevalence of adult ED patients presenting to three urban Canadian hospitals, and to determine whether there was an increased prevalence compared to the general public.MethodsA verbal questionnaire was administered to adult patients aged 18 years and older presenting to Royal University Hospital, St. Paul’s Hospital, and Saskatoon City Hospital in Saskatoon, Saskatchewan. We compared patients’ smoking habits to Fagerström tobacco dependence scores, readiness to quit smoking, chief complaints, Canadian Triage Acuity Scale scores, and willingness to partake in ED-specific cessation interventions.ResultsA total of 1190 eligible patients were approached, and 1078 completed the questionnaire. Adult Saskatoon ED patients demonstrated a cigarette smoking prevalence of 19.6%, which is significantly higher than the adult Saskatchewan public at 14.65% (P<0.0001). Out of the smoking cohort, 51.4% indicated they wanted to quit smoking and would partake in ED-specific cessation counselling, if available. Of the proposed interventions, ED cessation counselling was most popular among patients (62.4%), followed by receiving a pamphlet (56.2%), and referral to a smokers’ quit line (49.5%).ConclusionThe higher smoking prevalence demonstrated among ED patients highlights the need for a targeted intervention program that is feasible for the fast-paced ED environment. Training ED staff to conduct brief cessation counselling and referral to community supports for follow-up could provide an initial point of contact for smokers not otherwise receiving cessation assistance.

Assessment of ED triage of anaphylaxis patients based on the Emergency Severity Index

To describe the emergency department (ED) triage of anaphylaxis patients based on the Emergency Severity Index (ESI), assess the association between ESI triage level and ED epinephrine administration, and determine characteristics associated with lower acuity triage ESI assignment (levels 3 and 4). We conducted a cohort study of adult and pediatric anaphylaxis patients between September 2010 and September 2018 at an academic ED. Patient characteristics and management were compared between Emergency Severity Index (ESI) triage level 1 or 2 versus levels 3 or 4 using logistic regression analysis. We adhered to STROBE reporting guidelines. A total of 1090 patient visits were included. There were 26 (2%), 515 (47%), 489 (45%), and 60 (6%) visits that were assigned an ESI triage level of 1, 2, 3, and 4, respectively. Epinephrine was administered in the ED to 53% of patients triaged ESI level 1 or 2 and to 40% of patients triaged ESI level 3 or 4. Patients who were assigned a lower acuity ESI level of 3 or 4 had a longer median time from ED arrival to epinephrine administration compared to those with a higher acuity ESI level of 1 or 2 (28min compared to 13min, p<.001). A lower acuity ESI level was more likely to be assigned to visits with a chief concern of hives, rash, or pruritus (OR 2.33 [95% CI, 1.20-4.53]) and less likely to be assigned to visits among adults (OR, 0.43 [0.31-0.60]), patients who received epinephrine from emergency medical services (OR 0.56 [0.38-0.82]), presented with posterior pharyngeal or uvular angioedema (OR, 0.56 [0.38-0.82]), hypoxemia (OR, 0.34 [0.18-0.64]), or increased heart (OR 0.83 [0.73-0.95]) or respiratory (OR 0.70 [0.60-0.82]) rates. Patients triaged to lower acuity ESI levels experienced delays in ED epinephrine administration. Adult and pediatric patients with skin-related chief concerns were more likely to be to be assigned lower acuity ESI levels. Further studies are needed to identify interventions that will improve ED anaphylaxis triage.

Who Doesn't Come Home? Factors Influencing Mortality Among Long-Term Care Residents Transitioning to and From Emergency Departments in Two Canadian Cities.

Residents of long-term care (LTC) whose deaths are imminent are likely to trigger a transfer to the emergency department (ED), which may not be appropriate. Using data from an observational study, we employed structural equation modeling to examine relationships among organizational and resident variables and death during transitions between LTC and ED. We identified 524 residents involved in 637 transfers from 38 LTC facilities and 2 EDs. Our model fit the data, (χ2 = 72.91, df = 56, p = .064), explaining 15% variance in resident death. Sustained shortness of breath (SOB), persistent decreased level of consciousness (LOC) and high triage acuity at ED presentation were direct and significant predictors of death. The estimated model can be used as a framework for future research. Standardized reporting of SOB and changes in LOC, scoring of resident acuity in LTC and timely palliative care consultation for families in the ED, when they are present, warrant further investigation.

The influence of nurse allocated triage category on the care of patients with sepsis in the emergency department: A retrospective review

Background‘Gold standard’ sepsis care encompasses the recognition and treatment of sepsis within one hour of emergency department (ED) presentation. Early treatment of patients with sepsis reduces mortality. The aim of this study was to examine the effect that the nurse allocated Australasian Triage Scale (ATS) Category allocation had on ED patient treatment for severe sepsis and septic shock. MethodsA two-year retrospective observational cohort study from a single major metropolitan ED, including all patients with severe sepsis or septic shock. ResultsSixty patients were included in this study. Sepsis was recognised at triage for the majority of patients (n=38, 63%), and most were allocated an ATS Category Two (n=39). Almost half of the patients received all elements of the sepsis bundle within one hour of arrival (n=27,45%). Patients allocated an ATS Category One or Two had a shorter time to lactate collection (p=0.003), blood culture procurement (p=0.009) and intravenous antibiotic administration (p=0.021) compared with patients who were allocated ATS Category Three or Four. ConclusionsMost patients presenting with sepsis were recognised by the triage nurse and allocated a high acuity ATS category accordingly. As sepsis is a time-critical condition and a high acuity triage allocation reduces time to treatment, we recommend all Australian EDs should implement a standard approach to sepsis triage by allocating an ATS Category of One or Two to all patients suspected of having sepsis, thus reflecting the urgency of their disease.

Clinical factors associated with the use of dexamethasone for asthma in the pediatric emergency department

Background Dexamethasone is efficacious for the treatment of pediatric asthma exacerbations but is not specifically recommended by current national guidelines. Objectives To describe the factors associated with prescribed dexamethasone in a pediatric emergency department (PED) and upon patient discharge. Methods Retrospective chart review of patients aged 2 to 18 years discharged home from a PED with a diagnostic code for asthma (J45x). Descriptive statistics are reported and binary logistic regression with generalized estimating equations was used to examine the demographic and clinical factors associated with dexamethasone use in the PED and upon discharge. Results 594 children contributed 690 visits for asthma. Two-thirds of patients received prednisone in the PED (n = 430; 62%). Among 260 children who received dexamethasone, 76% (n = 198) were prescribed a second dose for post-discharge administration. Multivariable models showed that patients triaged as most urgent had a 50% reduction in the odds of receiving dexamethasone in the PED (OR = 0.5; 95% CI = 0.28–0.87). Patients seen by a pediatrician (OR 4.2; 95%CI 2.1–8.3) and those triaged as urgent (OR 2.9; 95% CI = 1.8–7.8) were more likely to receive a single dose of dexamethasone. Conclusions Dexamethasone is less commonly used in the PED for asthmatic patients triaged as most urgent. Triage acuity and level of training were associated with single-dose treatment of asthma in those receiving dexamethasone. Further studies are needed to clarify the use of dexamethasone across the spectrum of asthma severity.

Advancing Emergency Nurses’ Leadership and Practice through Informatics

Collection of data in healthcare is vitally important to inform healthcare resource planning and monitor effectiveness of care. The Canadian Emergency Department information System and Canadian Triage Acuity Scale are primary tools for collecting such data. Although emergency nurses use these tools to collect significant patient and healthcare data on daily basis, their understanding of the purposes and implications for collecting these data is sub-optimal. Furthermore, emergency nurses’ awareness about informatics, and the limited representation in information and communication technology strategic initiatives and research within Canadian emergency nursing are some barriers preventing nurses from realizing the full benefits of information and communication technology to improve patient and system outcomes, and nursing knowledge development. The National Emergency Nurses Association is well positioned to provide the leadership required to move nurses from being data collectors, to information users by maximizing their potential to advance Canadian emergency nursing practice through informatics.

Validity of a five-level prehospital triage system in Japan: A cohort study.

The increasing worldwide demand for ambulance transport may worsen patient prognosis due to a prolonged response time and overcrowding in the emergency department. Triage in the prehospital setting may reduce the demand for ambulance transport by advising low-acuity patients seek non-emergency medical care. In Japan, a five-level triage system that allows emergency medical services (EMS) to triage patients has been implemented since 2014. This study aimed to validate the five-level triage system. We conducted a retrospective cohort study in patients aged ≥16years who were transported by EMS to a tertiary-care hospital in Japan from April 2018 to June 2018. We used admission to the intensive care unit (ICU) as the primary outcome. Our secondary outcome was overall admission. We conducted multivariable logistic regression analysis to determine the strength of association between triage acuity and admission (ICU and overall). A total of 1261 patients were included in the analysis. The odds ratios of ICU admission were 9.62 (95% confidence interval: 5.66-16.3) in Level 1 and 2.93 (95% confidence interval: 1.60-5.38) in Level 2 compared with reference groups composed of Levels 4 and 5. Similar associations were found for triage acuity and overall admission. Our study validates the five-level prehospital triage system for patients transported by EMS and demonstrates an association between the triage acuity and ICU admissions.

Discharge in Pandemic: Suspected Covid-19 patients returning to the Emergency Department within 72 hours for admission.

IntroductionCoronavirus disease 2019 (Covid-19) has led to unprecedented healthcare demand. This study seeks to characterize Emergency Department (ED) discharges suspected of Covid-19 that are admitted within 72 h.MethodsWe abstracted all adult discharges with suspected Covid-19 from five New York City EDs between March 2nd and April 15th. Those admitted within 72 h were then compared against those who were not using descriptive and regression analysis of background and clinical characteristics.ResultsDischarged ED patients returning within 72 h were more often admitted if suspected of Covid-19 (32.9% vs 12.1%, p < .0001). Of 7433 suspected Covid-19 discharges, the 139 (1.9%) admitted within 72 h were older (55.4 vs. 45.6 years, OR 1.03) and more often male (1.32) or with a history of obstructive lung disease (2.77) or diabetes (1.58) than those who were not admitted (p < .05). Additional associations included non-English preference, cancer, heart failure, hypertension, renal disease, ambulance arrival, higher triage acuity, longer ED stay or time from symptom onset, fever, tachycardia, dyspnea, gastrointestinal symptoms, x-ray abnormalities, and decreased platelets and lymphocytes (p < .05 for all). On 72-h return, 91 (65.5%) subjects required oxygen, and 7 (5.0%) required mechanical ventilation in the ED. Twenty-two (15.8%) of the study group have since died.ConclusionSeveral factors emerge as associated with 72-h ED return admission in subjects suspected of Covid-19. These should be considered when assessing discharge risk in clinical practice.

What presents to a rural district emergency department: A case mix.

BackgroundThere is little information available on the range of conditions presenting to generalist run rural district hospital emergency departments (EDs) which are the first point of acute care for many South Africans.AimThis study aims to assess the range of acute presentations as well as the types of procedures required by patients in a rural district hospital context.SettingZithulele is a 147-bed district hospital in rural Eastern Cape.MethodsThis is a cross-sectional study assessing all patients presenting to the Zithulele hospital emergency department from 01 October 2015 to 31 December 2015. Data collected included the triage acuity using the South African Triage Scale system, patient demographics, diagnosis, outcome and procedures performed. Diagnoses were coded retrospectively according to the international statistical classification of diseases and related health problems version 10 (ICD 10).ResultsOf the 4 002 patients presenting to the ED during the study period, 2% were triaged as emergencies and 45% as non-urgent. The most common diagnostic categories were injuries, infections and respiratory illnesses respectively. Diagnoses from all broad categories of the ICD-10 were represented. 67% of patients required no procedure. Diagnostic procedures (n = 877) were more prevalent than therapeutic procedures (n = 377). Only 2.4% of patients were transferred to a referral centre acutely.ConclusionPatients with conditions from all categories of the ICD-10 present for management at rural district hospitals. Healthcare professionals working in this setting need to independently diagnose and manage a wide range of ED presentations and execute an assortment of procedures.

Social Determinants of Hallway Bed Use.

IntroductionHallway beds in the emergency department (ED) produce lower patient satisfaction and inferior care. We sought to determine whether socioeconomic factors influence which visits are assigned to hallway beds, independent of clinical characteristics at triage.MethodsWe studied 332,919 visits, across 189,326 patients, to two academic EDs from 2013–2016. We estimated a logistic model of hallway bed assignment, conditioning on payor, demographics, triage acuity, chief complaint, patient visit frequency, and ED volume. Because payor is not generally known at the time of triage, we interpreted it as a proxy for other observable characteristics that may influence bed assignment. We estimated a Cox proportional hazards model of hallway bed assignment on length of stay.ResultsMedian patient age was 53. 54.0% of visits were by women. 42.1% of visits were paid primarily by private payors, 37.1% by Medicare, and 20.7% by Medicaid. A total of 16.2% of visits were assigned to hallway beds. Hallway bed assignment was more likely for frequent ED visitors, for lower acuity presentations, and for psychiatric, substance use, and musculoskeletal chief complaints, which were more common among visits paid primarily by Medicaid. In a logistic model controlling for these factors, as well as for other patient demographics and for the volume of recent ED arrivals, Medicaid status was nevertheless associated with 22% greater odds of assignment to a hallway bed (odds ratio 1.22, [95% confidence interval, CI, 1.18–1.26]), compared to private insurance. Visits assigned to hallway beds had longer lengths of stay than roomed visits of comparable acuity (hazard ratio for departure 0.91 [95% CI, 0.90–0.92]).ConclusionWe find evidence of social determinants of hallway bed use, likely involving epidemiologic, clinical, and operational factors. Even after accounting for different distributions of chief complaints and for more frequent ED use by the Medicaid population, as well as for other visit characteristics known at the time of triage, visits paid primarily by Medicaid retain a disproportionate association with hallway bed assignment. Further research is needed to eliminate potential bias in the use of hallway beds. [West J Emerg Med. 2020;21(4)949–958.]

The development and validation of an obstetric triage acuity index: a mixed-method study

Background There is uncertainty about the applicability of developed country triage scales in the developing population. Objective To develop and validate an obstetric triage scale in Iran. Methods This exploratory sequential mixed-method study was conducted on experienced gynecologists, emergency medicine, midwives, and nurses as evaluators, and pregnant or parturient women as sample. Development of obstetric triage acuity index was done using qualitative study and literature review. Thirty-two evaluators in two rounds evaluated the clinical impact score, content validity ratio, and content validity index. The tool performance was compared with a standard reference in 415 women. The association of urgency levels with hospitalization, resource utilization, and emergency department length of stay were assessed in 599 women. Five midwives independently double-triaged 234 convenience women to estimate inter-rater reliability. Results Out of 191 items in the initial draft, 9 (4.7%) items in the face validity, 33 (18.1%) in the first, and 5 (3.2%) in the second content validity round were removed because not meeting the expected thresholds. Nine items added based on evaluators’ suggestions. Finally, total items had a kappa above 0.74, and S-CVI/Ave, S-CVI/UA were 0.99 and 0.86, respectively. There was a significant correlation between the two tools (r = 0.661, p < 0). Level 1 mothers had a higher chance of using ≥ 2 resources (OR = 16.4, 95% CI = 2.06–129.98) and hospitalization (OR = 18.0, 95% CI = 3.96–81.51) compared to the level 5, after adjusting for gestational age/postpartum, and referral method. Sensitivity, specificity, and accuracy of the scale in predicting hospitalization were 74.8% (95% CI = 69.73–79.49), 80.8% (95% CI = 73.60–86.74), and 76.7% (72.67–80.48), respectively. The over and under-triage rates were 6.1% and 17.1%, respectively. The absolute agreement inter-raters was 86.8%, and the linear weighted kappa was 0.86 (95% CI = 0.81–0.91). Conclusion The designed OB triage scale showed good validity and reliability in the tertiary teaching hospital. Studying this tool at lower levels, non-educational, and public hospitals are recommended for external validity testing.

Predictors of hospital admission for patients presenting with psychiatric emergencies: A retrospective, cohort study

BackgroundRising psychiatric visits represent a significant and growing burden for emergency departments (EDs) across Canada. For individual psychiatric conditions, there are likely a variety of demographic and social variables that may increase risk of resource intensive hospital admission. MethodsWe conducted a retrospective cohort study of all patients admitted into inpatient psychiatric units from two EDs in Kingston, Ontario, Canada from 2015 to 2018. We collected demographic and social variables from an electronic ED information system inclusive of all patients presenting to the ED with a mental health or addictions-related chief complaint. We used multivariate logistic regression models to identify predictors of psychiatric admission. ResultsA total of 23,814 patients (49.1% male, median age 33) were identified. Admitted patients (n=1838) tended to be older (49 vs. 31 years), have lower Canadian Triage Acuity Scale scores (2.6 vs. 3.0), arrive by ambulance (51% vs. 35%) or police (18% vs. 9%), and have longer lengths of stay (8.4 vs. 4.9 hours). Individuals with mood and psychotic disorders were more likely to require a hospital admission. ConclusionA variety of clinical and demographic variables increased the risk of hospital admissions for individuals with a variety of psychiatric disorders.

An epidemiological study of a patient population, triage category allocations and principal diagnosis within the emergency centres of a private healthcare group in the Emirate of Dubai, United Arab Emirates.

AimTo describe, compare and correlate the number of patients seen, their demographics, triage category allocations and principal diagnosis in four emergency centres; to better understand the patient population and triage practices in this setting.DesignAn observational, cross‐sectional, epidemiological study.MethodsElectronic medical records were retrospectively evaluated from patients triaged in each of the four emergency centres over six months. Descriptive statistics were used to describe the patient demographics and variance between triage category allocations.ResultsA total of 56,984 patient records were captured, with an equal gender split and the workforce being the largest patient population (20–50 years). Acute upper respiratory infection was the most prolific diagnosis, and lower acuity triage categories were allocated the most. There were inconsistencies in the application of triage systems between the emergency centres, the most obvious being the variance in triage system selection and application.

Obstetric triage systems: a systematic review of measurement properties (Clinimetric)

BackgroundSince labor and delivery units often serve as emergency units for pregnant women, the use of obstetric triage systems with poor or inadequate quality can lead to unintended consequences such as over and under-triage and so a waste of humans and financial resources. Therefore, this systematic review was conducted to evaluate the measurement properties of obstetric triage tools.MethodsPubMed, EMBASE, and Medline were searched to identify studies in October 2018 and were updated in May 2019. The risk of bias COSMIN checklist was used to evaluate the quality of the studies. The quality of every measurement property was appraised by the update criteria of COSMIN. Evidence quality was judged using the modified GRADE approach.ResultsA total of 444 studies were retrieved in initial search. Six studies evaluating 4 tools were included in this study. All the included studies reported only content validity and reliability. The quality of evidence varied from very low to moderate. The quality of content validity and reliability of the included tools was sufficient except for the reliability of the maternal-fetal triage index. The obstetric triage acuity scale (OTAS) was found to have higher reliability than other tools.ConclusionsDue to insufficient evidence, the conclusions about the quality of measurement properties of each obstetric triage tool may be uncertain. This review emphasizes the necessity for further studies with robust methodological quality on the measurement properties of obstetric triage tools.

Validation of the Cipto Triage Method: A Single-Centre Study from Indonesia.

PurposeA national referral hospital in Indonesia developed a three-category triage acuity method called the Cipto Triage Method (CTM) for emergency departments (ED) in developing countries. This was a validation study to assess the performance of the triage method.MethodsThis cohort, retrospective, single-centre study was conducted in the ED of Cipto Mangunkusumo Hospital that receives approximately 30,000 patient visits per year. The ED medical records throughout the year 2017 were randomly selected as the study sample. Completely written forms of triage and ED initial assessment were included in this study. Validation of the CTM decision was done by using expert panel opinion as reference standard, and also using surrogate conditions such as patient outcome for hospital admission and in-hospital mortality.ResultsThere were 1348 samples assigned to the following three categories: resuscitation (14.9%), urgent (63.8%) and non-urgent (21.3%). Overall accuracy was more than 80%, positive predictive value and negative predictive value for resuscitation category were 99% (95% confidence interval [CI], 96.5–99.9) and 96.9% (95% CI, 95.7−97.8), respectively. Resuscitation category had a relative risk (RR) for admission of 1.341 (95% CI, 1.259–1.429) and a RR for mortality of 4.294 (95% CI, 3.180–5.799). Undertriage increases the risk of mortality compared to correct triage (RR, 3.1; 95% CI, 2.11–4.54).ConclusionCTM has a good criterion and construct validity; it is also easy to understand and can accommodate a simple ED design in the majority of hospitals in Indonesia.

Reliability of Canadian triage acuity scale for toxicology cases that presented to Sultan Qaboos University Hospital Emergency Department, Oman

Reliability of Canadian triage acuity scale for toxicology cases that presented to Sultan Qaboos University Hospital Emergency Department, Oman

LO31: Triage drift: Variation in application of the Canadian Triage Acuity Scale between triage nurses compared to triage paramedics in response to overcrowding pressures in an emergency department

Introduction: CTAS is a validated five-level triage score utilized in EDs across Canada and internationally. Moderate interrater reliability between prehospital paramedic and triage nurse application of CTAS during clinical practice has been found. This study is the first assessment of the variation in distribution of CTAS scores with increasing departmental pressure as measured by the NEDOCs scale comparing triage allocations made by triage nurses with those made by triage paramedics. Methods: We conducted a retrospective, observational cohort study of EDIS data of all patients triaged in the Halifax Infirmary Emergency Department from January 1, 2017-May 30, 2017 and January 1, 2018 - May 30, 2018. CTAS score assignment by nursing and paramedic triage staff were compared with increasing levels of ED overcrowding, as determined by the department NEDOCS score. Results: Nurses were more likely to assign higher acuity scores in all situations of department crowding; there was a 3% increased probability that a nurse, as compared to a paramedic, would triage as emergent when the ED was not overcrowded (Pearson chi-square(1) = 4.21, p &lt; 0.05, Cramer's v = 0.028, n = 5314), and a 10% increased probability that a nurse, as compared to a paramedic, would triage a patient as emergent when EDs were overcrowded (Pearson chi-square(1) = 623.83, p &lt; 0.001, Cramer's v = 0.11, n = 56 018). Conclusion: Increasing levels of ED overcrowding influence triage nurse CTAS score assignment towards higher acuity to a greater degree than scores assigned by triage paramedics.

LO43: First Nations emergency care visits in Alberta: Descriptive results of a retrospective cohort study

Introduction: Emergency care serves as an important health resource for First Nations (FN) persons. Previous reporting shows that FN persons visit emergency departments at almost double the rate of non-FN persons. Working collaboratively with FN partners, academic researchers and health authority staff, the objective of this study is to investigate FN emergency care patient visit statistics in Alberta over a five year period. Methods: Through a population-based retrospective cohort study for the period from April 1, 2012 to March 31, 2017, patient demographics and emergency care visit characteristics for status FN patients in Alberta were analyzed and compared to non-FN statistics. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage Acuity Scale (CTAS)). Means and standard deviations (medians and interquartile ranges (IQR)) describe continuous variables (e.g., distances) as appropriate for the data distribution. These descriptions are repeated for the FN and non-FN populations, separately. Results: The data set contains 11,686,288 emergency facility visits by 3,024,491 unique persons. FN people make up 4.8% of unique patients and 9.4% of emergency care visits. FN persons live further from emergency facilities than their non-FN counterparts (FN median 6 km, IQR 1-24; vs. non-FN median 4 km, IQR 2-8). FN visits arrive more often by ground ambulance (15.3% vs. 10%). FN visits are more commonly triaged as less acute (59% CTAS levels 4 and 5, compared to non-FN 50.4%). More FN visits end in leaving without completing treatment (6.7% vs. 3.6%). FN visits are more often in the evening – 4:01pm to 12:00am (43.6% vs. 38.1%). Conclusion: In a collaborative validation session, FN Elders and health directors contextualized emergency care presentation in evenings and receiving less acute triage scores as related to difficulties accessing primary care. They explained presentation in evenings, arrival by ambulance, and leaving without completing treatment in terms of issues accessing transport to and from emergency facilities. Many factors interact to determine FN patients’ emergency care visit characteristics and outcomes. Further research needs to separate the impact of FN identity from factors such as reasons for visiting emergency facilities, distance traveled to care, and the size of facility where care is provided.

Children and adolescents with severe acute behavioural disturbance in the emergency department.

Mental health (MH) presentations to ED are increasing in children and adolescents. Little is known about patients with severe acute behavioural disturbance (ABD). We set out to describe patients with ABD severe enough to trigger an acute crisis team response in ED (termed 'Code Grey') and how they differ from other MH patients. Retrospective electronic medical record review of all ED patients with MH discharge codes at a tertiary children's hospital. We assessed the epidemiology and management of patients who triggered acute crisis team interventions (Code Grey) as proxy for severe ABD. We calculated the odds ratios (ORs with 95% confidence intervals) of key demographic factors compared to other MH patients. During 2018, there were 85 347 ED presentations of which 1695 (2.0%) were related to MH diagnoses; 84 MH patients had 141 MH presentations triggering 204 Code Greys (26 patients triggered 59% of Code Greys). These patients had higher triage acuity (OR 12.6 [8.3-19.0]), stayed longer in ED (>12 h OR 8.2 [5.1-13.1]) and were more likely to be admitted (OR 2.0 [1.4-3.0]) compared with non-Code Grey MH presentations. Patients were physically (19.2%), mechanically (31.9%) or chemically restrained (37.6%). Eight different medication approaches were used as either a single agent or a combination of oral and/or intramuscular agents. Children and adolescents with severe ABD differ from other MH presentations and often require physical or chemical restraint. Anticipatory management plans may be valuable for repeat presenters.