Triage Category Research Articles

Unplanned blood use within 24 hours of emergency department presentation: A cohort study in an ageing population.

This research aims to elucidate drivers of blood use in an older population, with a focus on unplanned transfusions following ED presentation. In a retrospective cohort study we examined 2015 data for ED presentations and blood use in two hospitals serving a population containing a high proportion (21%) of adults aged ≥65 years. Unplanned blood use was defined as any transfusion ≤24 h of presentation. Data were analysed by age, sex, Major Diagnostic Category, triage category and time to transfusion. A total of 5294 blood components were transfused, comprising red cells (n=3784), fresh frozen plasma (n=657), platelets (n=563) and cryoprecipitate (n=290). Men aged ≥65 years were the highest users (40%, 2107 components). Unplanned transfusions accounted for 28% (n=1057) of annual red cell use. Of 85 014 ED presentations, 494 (0.6%) were associated with unplanned red cell transfusion. Four Major Diagnostic Categories accounted for 81% (n=853) of unplanned red cell use: gastrointestinal (n=375), haematology (n=267), trauma (n=144) and cardiovascular (n=67). Over one-fifth of unplanned transfusions (21%, n=222 of 1057) were associated with ICD-10 codes for anaemia as a reason for presentation within the Haematology Major Diagnostic Category. Adults aged ≥65 years accounted for 62% of overall red cell use and 61% of transfusions ≤24 h of presentation. Odds of unplanned red cell transfusion increased with age, peaking at odds ratio 28.5 (95% confidence interval 14.2-57.4) in those aged 85 years and above. Unplanned blood use accounted for 28% of annual hospital blood consumption. Blood component use increased with age and was greatest in older men. A significant burden of anaemia treatment was identified by the ED.

Changes in Emergency Department Visits, Diagnostic Groups, and 28-Day Mortality Associated With the COVID-19 Pandemic: A Territory-Wide, Retrospective, Cohort Study

Study objectiveWe aimed to evaluate and characterize the scale and relationships of emergency department (ED) visits and excess mortality associated with the early phase of the COVID-19 pandemic in the territory of Hong Kong.MethodsWe conducted a territory-wide, retrospective cohort study to compare ED visits and the related impact of the COVID-19 pandemic on mortality. All ED visits at 18 public acute hospitals in Hong Kong between January 1 and August 31 of 2019 (n=1,426,259) and 2020 (n=1,035,562) were included. The primary outcome was all-cause mortality in the 28 days following an ED visit. The secondary outcomes were weekly number of ED visits and diagnosis-specific mortality.ResultsED visits decreased by 27.4%, from 1,426,259 in 2019 to 1,035,562 in 2020. Overall period mortality increased from 28,686 (2.0%) in 2019 to 29,737 (2.9%) in 2020. The adjusted odds ratio for 28-day, all-cause mortality in the pandemic period of 2020 relative to 2019 was 1.26 (95% confidence interval 1.24 to 1.28). Both sexes, age more than 45 years, all triage categories, all social classes, all ED visit periods, epilepsy (odds ratio 1.58, 95% confidence interval 1.20 to 2.07), lower respiratory tract infection, and airway disease had higher adjusted ORs for all-cause mortality.ConclusionA significant reduction in ED visits in the first 8 months of the COVID-19 pandemic was associated with an increase in deaths certified in the ED. The government must make provisions to encourage patients with alarming symptoms, mental health conditions, and comorbidities to seek timely emergency care, regardless of the pandemic.

Physiological deterioration in the Emergency Department: The SNAP40-ED study

Continuous novel ambulatory monitoring may detect deterioration in Emergency Department (ED) patients more rapidly, prompting treatment and preventing adverse events. Single-centre, open-label, prospective, observational cohort study recruiting high/medium acuity (Manchester triage category 2 and 3) participants, aged over 16 years, presenting to ED. Participants were fitted with a novel wearable monitoring device alongside standard clinical care (wired monitoring and/or manual clinical staff vital sign recording) and observed for up to 4 hours in the ED. Primary outcome was time to detection of deterioration. Two-hundred and fifty (250) patients were enrolled. In 82 patients (32.8%) with standard monitoring (wired monitoring and/or manual clinical staff vital sign recording), deterioration in at least one vital sign was noted during their four-hour ED stay. Overall, the novel device detected deterioration a median of 34 minutes earlier than wired monitoring (Q1, Q3 67,194; n=73, mean difference 39.48, p<0.0001). The novel device detected deterioration a median of 24 minutes (Q1, Q3 2,43; n=42) earlier than wired monitoring and 65 minutes (Q1, Q3 28,114; n=31) earlier than manual vital signs. Deterioration in physiology was common in ED patients. ED staff spent a significant amount of time performing observations and responding to alarms, with many not escalated. The novel device detected deterioration significantly earlier than standard care.

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids.

Background and aimsPharmaceutical opioids are a significant contributor to the global ‘opioid crisis’, yet few studies have comprehensively distinguished between opioid types. We measured whether a range of common pharmaceutical opioids varied in their contribution to the rates and characteristics of harm in a population‐wide indicator of non‐fatal overdose.DesignRetrospective observational study of emergency department (ED) patient care records in the Victorian Emergency Minimum Data set (VEMD), July 2009 to June 2019.SettingVictoria, Australia.CasesED presentations for non‐fatal overdose related to pharmaceutical opioid use (n = 5403), where the specific pharmaceutical opioid was documented.MeasurementsWe compared harms across the nine individual pharmaceutical opioids most commonly sold, and considered where multiple opioids contributed to the overdose. We calculated supply‐adjusted rates of ED presentations using Poisson regression and used multinomial logistic regression to compare demographic and clinical characteristics of presentations among nine distinct pharmaceutical opioids and a 10th category where multiple opioids were documented for the presentation.FindingsThere were wide differences, up to 27‐fold, between supply‐adjusted rates of overdose. When considering presentations with sole opioids, the highest supply‐adjusted overdose rates [per 100 000 oral morphine equivalents (OME); 95% confidence interval (CI)] were for codeine (OME = 0.078, 95% CI = 0.073–0.08) and oxycodone (OME =0.029, 95% CI = 0.027–0.030) and the lowest were for tapentadol (OME = 0.004, 95% CI = 0.003–0.006) and fentanyl (OME = 0.003, 95% CI = 0.002–0.004). These rates appeared related to availability rather than opioid potency. Most (62%) poisonings involved females. Codeine, oxycodone and tramadol were associated with younger presentations (respectively, 59.5%, 41.7% and 49.8% of presentations were 12‐34 years old), and intentional self‐harm (respectively 65.2%, 50.6%, and 52.8% of presentations). Relative to morphine, fentanyl [ 0.32 relative risk ratio (RRR)] and methadone ( 0.58 RRR) presentations were less likely to be coded as self‐harm. Relative to morphine–buprenorphine, codeine, oxycodone and tramadol presentations were significantly more likely to be associated with the less urgent triage categories (respectively 2.18, 1.80, 1.52, 1.65 RRR).ConclusionsIn Victoria, Australia, rates and characteristics of emergency department presentations for pharmaceutical opioids show distinct variations by opioid type.

Sex differences in clinical presentation and risk stratification in the Emergency Department: An observational multicenter cohort study

ObjectiveThe aim of this study was to investigate whether sex differences exist in disease presentations, disease severity and (case-mix adjusted) outcomes in the Emergency Department (ED). MethodsObservational multicenter cohort study using the Netherlands Emergency Department Evaluation Database (NEED), including patients ≥ 18 years of three Dutch EDs. Multivariable logistic regression was used to study the associations between sex and outcome measures in-hospital mortality and Intensive Care Unit/Medium Care Unit (ICU/MCU) admission in ED patients and in subgroups triage categories and presenting complaints. ResultsOf 148,825 patients, 72,554 (48.8%) were females. Patient characteristics at ED presentation and diagnoses (such as pneumonia, cerebral infarction, and fractures) were comparable between sexes at ED presentation. In-hospital mortality was 2.2% in males and 1.7% in females. ICU/MCU admission was 4.7% in males and 3.1% in females. Males had higher unadjusted (OR 1.34(1.25–1.45)) and adjusted (AOR 1.34(1.24–1.46)) risks for mortality, and unadjusted (OR 1.54(1.46–1.63)) and adjusted (AOR 1.46(1.37–1.56)) risks for ICU/MCU admission. Males had higher adjusted mortality and ICU/MCU admission for all triage categories, and with almost all presenting complaints except for headache. ConclusionsAlthough patient characteristics at ED presentation for both sexes are comparable, males are at higher unadjusted and adjusted risk for adverse outcomes. Males have higher risks in all triage categories and with almost all presenting complaints. Future studies should investigate reasons for higher risk in male ED patients.

Effects of Relaxed Lockdown on Pediatric ER Visits during SARS-CoV-2 Pandemic in Italy.

Previously, we demonstrated an 81% reduction in pediatric Emergency Room (ER) visits in Italy during the strict lockdown due to the SARS-CoV-2 pandemic. Since May 2020, lockdown measures were relaxed until 6 November 2020, when a strict lockdown was patchily reintroduced. Our aim was to evaluate the impact of the relaxed lockdown on pediatric ER visits in Italy. We performed a retrospective multicenter study involving 14 Italian pediatric ERs. We compared total ER visits from 24 September 2020 to 6 November 2020 with those during the corresponding timeframe in 2019. We evaluated 17 ER specific diagnoses grouped in air communicable and non-air communicable diseases. We recognized four different triage categories: white, green, yellow and red. In 2020 total ER visits were reduced by 51% compared to 2019 (16,088 vs. 32,568, respectively). The decrease in air communicable diseases was significantly higher if compared to non-air communicable diseases (−64% vs. −42%, respectively). ER visits in each triage category decreased in 2020 compared to 2019, but in percentage, white and red codes remained stable, while yellow codes slightly increased and green codes slightly decreased. Our results suggest that preventive measures drastically reduced the circulation of air communicable diseases even during the reopening of social activities but to a lesser extent with regard to the strict lockdown period (March–May 2020).

Validation of Australian and Victorian guidelines for colonoscopy triage.

Managing the growing demand for colonoscopies is challenging. To assess the diagnostic performance of National and Victorian colonoscopy triage guidelines and potential redistribution of triage categories. This is a diagnostic validation study comparing colonoscopy triage guidelines against a reference colonoscopy dataset. Participants were a reference dataset of 2378 colonoscopies from 1 October 2014 to 30 June 2016. Comparison with triage categorisation determined using National Cancer Council Australia guidelines; Victorian triage guidelines; Optimal Cancer Care Pathways recommendations. Main outcome measures were as follows: (i) proportion of colonoscopies assigned to each triage category; (ii) detection rate (proportion of cancers assigned to triage Category 1); and (iii) conversion rate (proportion of triage Category 1 colonoscopies that diagnose a cancer). After adjusting for data absent in referrals, the National and Victorian guidelines reduced the proportion of Category 1 colonoscopies compared with the reference triage (National 76.3% vs 58.6%; 95% CI for difference 15.0-20.3%, P < 0.0001. Victorian 76.3% vs 66.3%; 95% CI for difference 7.4-12.6%, P < 0.0001). Victorian guidelines were associated with the highest detection rate (91.4%) and a conversion rate of 5.4% although the number of cancers limited the power to detect significant differences on these metrics. There was a higher proportion of unclassifiable colonoscopies using the National guidelines than the Victorian ones due to their focus on symptomatic indications. The Victorian guidelines could reduce the proportion of Category 1 colonoscopies by 10% without reducing conversion or detection rates. This would require improvements in the quality of referrals and ordering faecal occult blood tests in 6% of symptomatic patients.

THE ROLE OF ARTIFICIAL INTELLIGENCE IN TRIAGE AT THE EMERGENCY DEPARTMENT

New trends of integrating the emergency medicine services with non-medical technology could lead to new solutions that would improve and transform the quality of emergency medical care. In recent years, there has been an increased need for artificial intelligence in various fields, where it is used to simplify complex decision-making. Artificial intelligence is also eminent in the future of patient care and effectiveness, not only at the emergency department, but throughout the health care system. Its task is to create a system that thinks like a human and acts rationally. Emergency patients are a particularly vulnerable group of people who require an individual approach, and recognising various priorities of care in the emergency patient will determine the quality of triage. Despite the knowledge, skills, precision and reliability of the highly educated personnel providing triage, the fact is that they use both objective and subjective assessments in their actions, and these are prone to error. Derogations in determining triage categories could be reduced, and a possible solution is the use of artificial intelligence to support the triage system. Communications between health care institutions, in the sense of the exchange and updating of digital data, would further facilitate the work-up of the emergency patient, and result in faster, better triage decisions. In observing the data collected at the emergency departments, a certain range of derogations in triage decisions is evident. A comparison of data from multiple hospital institutions showed that the frequency of specific triage categories differs. With the connection and optimisation of information systems, it could be assumed that artificial intelligence could provide great benefits in determining triage categories. The system would have access to a greater quantity of data that would then allow for a more satisfactory triage outcome. This would also improve the reaction time to similar or the same measurement procedures when performing algorithmic forecasts of data for determining the triage category. Though there are certain barriers to introducing any novelty, the partnership between human and artificial intelligence in triage is desirable, as together the chance for error is dramatically reduced. Combining artificially produced precision, generated from collected and machine learned data, with the human factor based on emotions, empathy and intuition, are a requirement for more uniform and better care of the emergency patient.

Improving Diagnostic Testing Decisions for Pediatric Minor Head Trauma in the Emergency Department: A Two‐Year Prospective Implementation Study

Research ObjectiveThe risk of serious intracranial injury in pediatric patients with minor head trauma (MHT) is less than 5%; most computerized tomography (CT) scans in MHT are normal or contribute little to management, yet expose children to unnecessary radiation. Despite evidence‐based risk classification criteria from the Pediatric Emergency Care Applied Research Network (PECARN) for assessing appropriate CT use during emergency department (ED) visits, barriers persist to replacing unnecessary scans with structured observation. Field readiness assessments at Intermountain Healthcare suggest that physicians often believe they know the risk factors for traumatic brain injury (TBI) but sometimes misremember elements. Information retrieval when delivering ED care can be cumbersome. Many physicians also perceive ordering CT scans is the safest course of action despite a lack of significant symptoms. We theorized that targeting evidence‐based education at the individual scan decision point, coupled with timely performance feedback, would increase cognitive support for assessing risk of clinically‐important TBI (ciTBI), reducing potentially unnecessary scans.Study DesignWe conducted a prospective pre‐post comparison implementation study. The primary implementation strategies were two‐fold. First, we embedded an alert containing an easy‐to‐understand, information‐rich graphic providing current PECARN risk stratification criteria and supporting evidence for classifying ciTBI, along with a risk assessment prompt linked to a CT order. Second, we provided timely feedback on performance and local prompting to educate physicians. Uptake and effectiveness measures included % adherence change in PECARN guidelines and the CT scan rate. Safety was evaluated by counting 48‐hour readmissions with clinical evidence of ciTBI confirmed via chart review. Acceptability, fidelity and feasibility were assessed using qualitative analysis. Statistical analysis was conducted using tests of proportions.Population StudiedApproximately 14,000 pediatric patients presenting with MHT at 22 EDs from January 2019–December 2020 within a single, integrated delivery system including urban, rural and frontier locations and a children's hospital.Principal FindingsYear 1 adherence to PECARN guidelines was 98.7% with a 14% reduction in the CT scan rate for pediatric MHT patients across geographies with no readmissions for ciTBI (Table). Results were sustained in Year 2 despite increased patient acuity in 2020 due to the novel coronavirus pandemic. Subsequent field discussions found good acceptance by physicians noting the alert was relevant, timely and easy to understand. Implementation fidelity was high given routinization of the alert into clinical workflow.ConclusionsCombining local performance feedback with use of an information‐rich text alert was associated with significant improvements in adherence to PECARN guidelines and a reduction in the CT scan order rate for diagnosis of clinically‐important TBI in MHT patients without impacting safety. The routinized nature of the alert was associated with good practice sustainment over multiple years across geographies.Implications for Policy or PracticeSimple, information‐rich text alerts may prove useful as an implementation strategy for updating physicians on changes in evidence‐based triage and risk classification criteria often associated with de‐implementation of legacy clinical practices. Measure Baseline‐Dec2018 Rolling‐6mo Uptake‐Dec2019 Rolling‐12mo Sustainment‐Dec2020 Rolling‐12mo z‐score/p‐value % adherence to PECARN guidelines 95.66% 98.74% 99.32% z = −10.3; p &lt; 0.001 CT scan rate 33% 29% 29% z = 6.0; p &lt; 0.001 48‐hour readmission for ciTBI 0 0 0

A Machine Learning Methodology for Identification and Triage of Heart Failure Exacerbations

Inadequate at-home management and self-awareness of heart failure (HF) exacerbations are known to be leading causes of the greater than 1 million estimated HF-related hospitalizations in the USA alone. Most current at-home HF management protocols include paper guidelines or exploratory health applications that lack rigor and validation at the level of the individual patient. We report on a novel triage methodology that uses machine learning predictions for real-time detection and assessment of exacerbations. Medical specialist opinions on statistically and clinically comprehensive, simulated patient cases were used to train and validate prediction algorithms. Model performance was assessed by comparison to physician panel consensus in a representative, out-of-sample validation set of 100 vignettes. Algorithm prediction accuracy and safety indicators surpassed all individual specialists in identifying consensus opinion on existence/severity of exacerbations and appropriate treatment response. The algorithms also scored the highest sensitivity, specificity, and PPV when assessing the need for emergency care.Lay summaryHere we develop a machine-learning approach for providing real-time decision support to adults diagnosed with congestive heart failure. The algorithm achieves higher exacerbation and triage classification performance than any individual physician when compared to physician consensus opinion.Graphical abstract

Emergency medicine patient wait time multivariable prediction models: a multicentre derivation and validation study

ObjectivePatients, families and community members would like emergency department wait time visibility. This would improve patient journeys through emergency medicine. The study objective was to derive, internally and externally validate...

Paediatric major incident triage: UK military tool offers best performance in predicting the need for time-critical major surgical and resuscitative intervention.

BackgroundChildren are frequently injured during major incidents (MI), including terrorist attacks, conflict and natural disasters. Triage facilitates healthcare resource allocation in order to maximise overall survival. A critical function of MI triage tools is to identify patients needing time-critical major resuscitative and surgical intervention (Priority 1 (P1) status). This study compares the performance of 11 MI triage tools in predicting P1 status in children from the UK Trauma Audit and Research Network (TARN) registry.MethodsPatients aged <16 years within TARN (January 2008-December 2017) were included. 11 triage tools were applied to patients’ first recorded pre-hospital physiology. Patients were retrospectively assigned triage categories (P1, P2, P3, Expectant or Dead) using predefined intervention-based criteria. Tools’ performance in <16s were evaluated within four-yearly age subgroups, comparing tool-predicted and intervention-based priority status.FindingsAmongst 4962 patients, mortality was 1.1% (n = 53); median Injury Severity Score (ISS) was 9 (IQR 9–16). Blunt injuries predominated (94.4%). 1343 (27.1%) met intervention-based criteria for P1, exhibiting greater intensive care requirement (60.2% vs. 8.5%, p < 0.01) and ISS (median 17 vs 9, p < 0.01) compared with P2 patients. The Battlefield Casualty Drills (BCD) Triage Sieve had greatest sensitivity (75.7%) in predicting P1 status in children <16 years, demonstrating a 38.4–49.8% improvement across all subgroups of children <12 years compared with the UK's current Paediatric Triage Tape (PTT). JumpSTART demonstrated low sensitivity in predicting P1 status in 4 to 8 year olds (35.5%) and 0 to 4 year olds (28.5%), and was outperformed by its adult counterpart START (60.6% and 59.6%).InterpretationThe BCD Triage Sieve had greatest sensitivity in predicting P1 status in this paediatric trauma registry population: we recommend it replaces the PTT in UK practice. Users of JumpSTART may consider alternative tools. We recommend Lerner's triage category definitions when conducting MI evaluations.

An Australian tertiary hospital analysis of outpatient dermatology clinical and demographic characteristics.

Literature on dermatology outpatient demographic and clinical data is limited, and the few studies on this topic are mainly conducted overseas, with medical systems and case mix different to Australia. This study presents demographic data relating to dermatology public outpatient referrals to a tertiary hospital in Brisbane, Australia, and determines what additional structured data should be collected to formulate and evaluate initiatives to address service issues such as referral quality, triage process and wait times. A four-year retrospective audit was undertaken, summarising all referrals (n = 7140) and clinical dermatology encounters (n = 53 844) between January 2016 and December 2019 at Princess Alexandra Hospital (PAH), the largest hospital in Metro South Health (MSH), serving a population of one million. PAH has one of the two largest public dermatology clinics in Queensland and is the only dermatology service within MSH. Patient demographic data, wait time by triage category, referral rates over time and encounter durations were collected. Structured diagnostic data (e.g. ICD-10 coding) of the provisional diagnosis, comorbidities, medications and the final diagnosis are not collected in a structured format and would be a valuable addition. The clinical burden of public dermatology is increasing. Both collection and analysis of structured data pertaining to the referrals and encounters are important to help formulate, implement and evaluate initiatives that aim to improve health service provision in this area.

Outcomes for emergency department patients with suspected and confirmed COVID-19: An analysis of the Australian experience in 2020 (COVED-5).

ObjectiveThe aim of the present study was to describe the characteristics and outcomes of patients presenting to Australian EDs with suspected and confirmed COVID‐19 during 2020, and to determine the predictors of in‐hospital death for SARS‐CoV‐2 positive patients.MethodsThis analysis from the COVED Project presents data from 12 sites across four Australian states for the period from 1 April to 30 November 2020. All adult patients who met local criteria for suspected COVID‐19 and underwent testing for SARS‐CoV‐2 in the ED were eligible for inclusion. Study outcomes were mechanical ventilation and in‐hospital mortality.ResultsAmong 24 405 eligible ED presentations over the whole study period, 423 tested positive for SARS‐CoV‐2. During the ‘second wave’ from 1 July to 30 September 2020, 26 (6%) of 406 SARS‐CoV‐2 patients received invasive mechanical ventilation, compared to 175 (2%) of the 9024 SARS‐CoV‐2 negative patients (odds ratio [OR] 3.5; 95% confidence interval [CI] 2.3–5.2, P < 0.001), and 41 (10%) SARS‐CoV‐2 positive patients died in hospital compared to 312 (3%) SARS‐CoV‐2 negative patients (OR 3.2; 95% CI 2.2–4.4, P = 0.001). For SARS‐CoV‐2 positive patients, the strongest independent predictors of hospital death were age (OR 1.1; 95% CI 1.1–1.1, P < 0.001), higher triage category (OR 3.5; 95% CI 1.3–9.4, P = 0.012), obesity (OR 4.2; 95% CI 1.2–14.3, P = 0.024) and receiving immunosuppressive treatment (OR 8.2; 95% CI 1.8–36.7, P = 0.006).ConclusionsED patients who tested positive for SARS‐CoV‐2 had higher odds of mechanical ventilation and death in hospital. The strongest predictors of death were age, a higher triage category, obesity and receiving immunosuppressive treatment.

Impact of lockdowns on critical care service demand in a metropolitan hospital in Melbourne, Australia.

There is a growing recognition of the impact of lockdowns on non-COVID-19 demand for critical care services. While a reduction in demand has been postulated, there remains a paucity of quantitative data on the extent and nature of this reduction. The present study aims to quantify the impact of lockdown on critical care services, namely ED, intensive care unit (ICU), medical emergency team (MET) and emergency theatre (ET) demand, during the lockdown in Victoria, Australia. This is a single-centred, retrospective observational study on critical service demand, comparing activity levels during the lockdown (31 March to 27 October 2020) with the matched time period from 1year prior. There was a reduction in presentations to ED (27.2%), MET calls (27.4%), ICU patient episodes (14.5%) and ET bookings (5.8%). There was an unexpected increase in ICU admissions for metabolic diagnoses, comprising drug overdoses and diabetic ketoacidosis, and a reduction in respiratory ICU admissions. There was a reduction across all ED triage categories, which included triage 1 and 2 patients, indicating a reduction even in life-threatening and emergency presentations. Lockdowns lead to a significant reduction in ICU, MET call and ED demand, and to a lesser extent ET demand. This pattern should be considered in surge capacity and workforce redeployment planning. There are also impacts on public health epidemiology, with potential adverse consequences on mental health and chronic disease management. Further research on the impact of lockdowns on long-term disease outcomes is needed.

Impact of assessment and intervention by a health and social care professional team in the emergency department on the quality, safety, and clinical effectiveness of care for older adults: A randomised controlled trial.

Older adults frequently attend the emergency department (ED) and experience high rates of adverse events following ED presentation. This randomised controlled trial evaluated the impact of early assessment and intervention by a dedicated team of health and social care professionals (HSCPs) in the ED on the quality, safety, and clinical effectiveness of care of older adults in the ED. This single-site randomised controlled trial included a sample of 353 patients aged ≥65 years (mean age = 79.6, SD = 7.01; 59.2% female) who presented with lower urgency complaints to the ED a university hospital in the Mid-West region of Ireland, during HSCP operational hours. The intervention consisted of early assessment and intervention carried out by a HSCP team comprising a senior medical social worker, senior occupational therapist, and senior physiotherapist. The primary outcome was ED length of stay. Secondary outcomes included rates of hospital admissions from the ED; hospital length of stay for admitted patients; patient satisfaction with index visit; ED revisits, mortality, nursing home admission, and unscheduled hospital admission at 30-day and 6-month follow-up; and patient functional status and quality of life (at index visit and follow-up). Demographic information included the patient's gender, age, marital status, residential status, mode of arrival to the ED, source of referral, index complaint, triage category, falls, and hospitalisation history. Participants in the intervention group (n = 176) experienced a significantly shorter ED stay than the control group (n = 177) (6.4 versus 12.1 median hours, p < 0.001). Other significant differences (intervention versus control) included lower rates of hospital admissions from the ED (19.3% versus 55.9%, p < 0.001), higher levels of satisfaction with the ED visit (p = 0.008), better function at 30-day (p = 0.01) and 6-month follow-up (p = 0.03), better mobility (p = 0.02 at 30 days), and better self-care (p = 0.03 at 30 days; p = 0.009 at 6 months). No differences at follow-up were observed in terms of ED re-presentation or hospital admission. Study limitations include the inability to blind patients or ED staff to allocation due to the nature of the intervention, and a focus on early assessment and intervention in the ED rather than care integration following discharge. Early assessment and intervention by a dedicated ED-based HSCP team reduced ED length of stay and the risk of hospital admissions among older adults, as well as improving patient satisfaction. Our findings support the effectiveness of an interdisciplinary model of care for key ED outcomes. ClinicalTrials.gov NCT03739515; registered on 12 November 2018.

Validation of the Interagency Integrated Triage Tool in a resource-limited, urban emergency department in Papua New Guinea: a pilot study

BackgroundThe Interagency Integrated Triage Tool (IITT) is a three-tier triage system designed for resource-limited emergency care (EC) settings. This study sought to assess the validity and reliability of a pilot version of the tool in an urban emergency department (ED) in Papua New Guinea. MethodsA pragmatic observational study was conducted at Gerehu General Hospital in Port Moresby, commencing eight weeks after IITT implementation. All ED patients presenting within the subsequent two-month period were included. Triage assessments were performed by a variety of ED clinicians, including community health workers, nurses and doctors. The primary outcome was sensitivity for the detection of time-critical illness, defined by ten pre-specified diagnoses. The association between triage category and ED outcomes was examined using Cramer's V correlation coefficient. Reliability was assessed by inter-rater agreement between a local and an experienced, external triage officer. FindingsAmong 4512 presentations during the study period, 58 (1.3%) were classified as category one (emergency), 967 (21.6%) as category two (priority) and 3478 (77.1%) as category three (non-urgent). The tool's sensitivity for detecting the pre-specified set of time-sensitive conditions was 70.8% (95%CI 58.2-81.4%), with negative predictive values of 97.3% (95%CI 96.7 - 97.8%) for admission/transfer and 99.9% (95%CI 99.7 - 100.0%) for death. The admission/transfer rate was 44.8% (26/58) among emergency patients, 22.9% (223/976) among priority patients and 2.7% (94/3478) among non-urgent patients (Cramer's V=0.351, p=0.00). Four of 58 (6.9%) emergency patients, 19/976 (2.0%) priority patients and 3/3478 (0.1%) non-urgent patients died in the ED (Cramer's V=0.14, p=0.00). The under-triage rate was 2.7% (94/3477) and the over-triage rate 48.2% (28/58), both within pre-specified limits of acceptability. On average, it took staff 3 minutes 34 seconds (SD 1:06) to determine and document a triage category. Among 70 observed assessments, weighted κ was 0.84 (excellent agreement). InterpretationThe pilot version of the IITT demonstrated acceptable performance characteristics, and validation in other EC settings is warranted. FundingThis project was funded through a Friendship Grant from the Australian Government Department of Foreign Affairs and Trade and an International Development Fund Grant from the Australasian College for Emergency Medicine Foundation.

The role and contribution of family carers accompanying community-living older people with cognitive impairment to the emergency department: An interview study.

Older people with cognitive impairment may have lack of understanding of their health and ability to co-ordinate care needs. Family carers play a key role in supporting older people but the role of family carers in emergency discharge has not been explored well. To explore and describe the role and contribution of family carers accompanying the older person with cognitive impairment to the emergency department. A exploratory descriptive study was conducted in which telephone interviews were performed. Three emergency departments located in metropolitan Sydney, Australia; two major tertiary referral centres and one district hospital. The EQUATOR research checklist (COnsolidated criteria for REporting Qualitative research) (COREQ) was used to report the qualitative study. Participants were family carers accompanying people aged ≥64years with cognitive impairment; with non-urgent triage classifications; English speaking and eligible for discharge home. Semi-structured telephone interviews were conducted 2 to 4weeks after the older person was discharged. Data were reflexively thematically analysed in NVIVO independently by three researchers. Twenty-eight interviews were conducted. Three key themes were evident: (1) 'communicating knowledge of the older person's health status and usual behaviour'; (2) 'providing advocacy, translation, surrogacy and care co-ordination'; and (3) 'ensuring safe transition from the emergency department to home'. Study findings detailed how family carers created an important safety net while the older person was in emergency, through advocacy and the communication of vital health information. More importantly, their knowledge influenced the healthcare management of the older person and ensured safe discharge and co-ordination of care in the community. The study identified for older persons with cognitive impairment a safe stay in the ED and transition home from hospital was supported by family carers and assisted to ensure that discharge information was understood and adhered to optimise wellbeing and prevent adverse outcomes. The findings of this study can inform discharge processes for nurses, nurse practitioners and doctors. Additionally, processes to support family carer engagement would optimise older person compliance and better inform healthcare decision-making and choice for older peoples, family carers. The findings of the study should inform discharge processes to minimise risk of readmission, financial burden and harm.

Point-of-care ultrasound for treatment and triage in austere military environments.

Assessment and triage in an austere environment represent a major challenge in casualty care. Modern conflicts involve a significant proportion of multiple wounds, either superficial or penetrating, which complicate clinical evaluation. Furthermore, there is often poor accessibility to computed tomography scans and a limited number of surgical teams. Therefore, ultrasound (US) represents a potentially valuable tool for distinguishing superficial fragments or shrapnels from penetrating trauma requiring immediate damage-control surgery. This retrospective observational multicenter study assessed casualties treated for 8 months by five medical teams deployed in Africa and Middle East. Two experts, who were experienced in military emergency medicine but did not take part in the missions, carried out an independent analysis for each case, evaluating the contribution of US to the following five items: triage categorization, diagnosis, clinical severity, prehospital therapeutic choices, and priority to operation room. Consensus was obtained using the Delphi method with three rounds. Of 325 casualties, 189 underwent US examination. The mean injury severity scale score was 25.6, and 76% were wounded by an improvised explosive device. Ultrasound was useful for confirming (23%) or excluding (63%) the suspected diagnosis made in the clinical assessment. It also helped obtain a diagnosis that had not been considered for 3% of casualties and was responsible for a major change in procedure or therapy in 4%. Ultrasound altered the surgical priority in 43% of cases. For 30% of cases, US permitted surgery to be temporarily delayed to prioritize another more urgent casualty. Ultrasound is a valuable tool for the management of mass casualties by improving treatment and triage, especially when surgical resources are limited. In some situations, US can also correct a diagnosis or improve prehospital therapeutic choices. Field medical teams should be trained to integrate US into their prehospital protocols. Case series (no criterion standard), level V.

Validation of the Pediatric Canadian Triage and Acuity Scale at the Emergency Department of a Tertiary Children's Hospital in Costa Rica.

Background: The Pediatric Canadian Triage and Acuity Scale (PedCTAS) is a recognized system that prioritizes care by the severity of illness. The goal of this study was to describe and analyze the results from the implementation of the PedCTAS in a tertiary children’s hospital in Costa Rica.Methods: This was a retrospective observational study of children presenting to the emergency department (ED) from 1st January to 31st December of 2019 in the only children’s hospital in Costa Rica. Outcome measures were hospitalization, ICU admission, waiting times from triage to physician time (TPT), left without being seen (LWBS), length of stay (LOS), in relation to the triage level, and final disposition.Results: A total of 93,001 patients were admitted to the ED. The proportion for hospitalizations according to triage category was 85.3%, 40%, 14%, 4.3%, and 2% for patients triaged at CTAS levels I, II, III, IV, and V respectively. A total of 2045 (2.19%) patients were LWBS. Some 585 (0.62%) patients were admitted to ICU. Median TPT for each category was for levels I:12 min, II:20 min, III:22 min, IV:34 min, and V:54 min. The LOS in the ED patients triaged as levels I and II stayed longer and the mortality rate was also higher in patients classified as levels I and II. The mortality rate was for level I patients 44.2% (23 patients) and level II 1.4% (8 patients).Conclusions: This study shows evidence of validation of the PedCTAS in a developing country in Latin America. Implementation of a validated triage tool in our country helps us to provide improvements in the care of pediatric patients in the ED.