Triage Category Research Articles

Overtriage, Undertriage, and Value of Care after Major Surgery: An Automated, Explainable Deep Learning-Enabled Classification System.

In single-institution studies, overtriaging low-risk postoperative patients to ICUs has been associated with a low value of care; undertriaging high-risk postoperative patients to general wards has been associated with increased mortality and morbidity. This study tested the reproducibility of an automated postoperative triage classification system to generating an actionable, explainable decision support system. This longitudinal cohort study included adults undergoing inpatient surgery at two university hospitals. Triage classifications were generated by an explainable deep learning model using preoperative and intraoperative electronic health record features. Nearest neighbor algorithms identified risk-matched controls. Primary outcomes were mortality, morbidity, and value of care (inverted risk-adjusted mortality/total direct costs). Among 4,669 ICU admissions, 237 (5.1%) were overtriaged. Compared with 1,021 control ward admissions, overtriaged admissions had similar outcomes but higher costs ($15.9K [interquartile range $9.8K to $22.3K] vs $10.7K [$7.0K to $17.6K], p < 0.001) and lower value of care (0.2 [0.1 to 0.3] vs 1.5 [0.9 to 2.2], p < 0.001). Among 8,594 ward admissions, 1,029 (12.0%) were undertriaged. Compared with 2,498 control ICU admissions, undertriaged admissions had longer hospital length-of-stays (6.4 [3.4 to 12.4] vs 5.4 [2.6 to 10.4] days, p < 0.001); greater incidence of hospital mortality (1.7% vs 0.7%, p = 0.03), cardiac arrest (1.4% vs 0.5%, p = 0.04), and persistent acute kidney injury without renal recovery (5.2% vs 2.8%, p = 0.002); similar costs ($21.8K [$13.3K to $34.9K] vs $21.9K [$13.1K to $36.3K]); and lower value of care (0.8 [0.5 to 1.3] vs 1.2 [0.7 to 2.0], p < 0.001). Overtriage was associated with low value of care; undertriage was associated with both low value of care and increased mortality and morbidity. The proposed framework for generating automated postoperative triage classifications is reproducible.

Use of a trauma registry to drive improvement in the regional trauma network systems in Hawassa, Ethiopia

AimOur aim is to establish and analyse the first year of trauma registry data from Hawassa University Comprehensive Specialised Hospital (HUCSH)—an Ethiopian tertiary referral centre. We plan to identify possible trends in injury patterns, access to health care and referral pathways and establish if our observations are in keeping with data published from other sub-Saharan LMIC’s.MethodsProspective data collection using the WHO trauma registry dataset. All trauma patients presenting to HUCSH between November 2019 and November 2020 were included. Military patients were excluded. Dataset: Age, sex, region of residence, mode of transport to hospital, referral centre, time from injury to arrival in HUCSH, arrival triage category, Kampala Trauma Score (KTS), mechanism of injury, injury type, closed/open fracture and 24 h outcomes. Data statistical analysis was performed to calculate frequencies of the above variables.ResultsThere were a total of 1919 cases. Fifty-three per cent were caused by road traffic collision and 49% were fracture/dislocations. Public transport was the most common mode to hospital—40%. Seventy-seven per cent of all trauma admissions were referred from other centres, 69% had a mild KTS. A total of 376 patients presented with an open fracture—76% had a low KTS and 67% remained in ED for > 24 h. Sixty-five per cent of ambulances were utilised for mild KTS patients, only 25% of ambulances transported moderate and severe injuries.ConclusionWe have shown that a ‘one size fits all approach’ should not be adopted for LMIC’s as trends vary between regions and countries. Improvements are needed in ambulance utilisation, the use of appropriate triaging tools to facilitate initial basic trauma care and appropriate, timely referrals and the management of open fractures.

Outcomes of paediatric patients who are not transported to hospital by Emergency Medical Services: a data linkage study

BackgroundData on the safety of non-transport decisions for paediatric patients attended by Emergency Medical Services (EMS) are lacking. We describe the characteristics and outcomes of paediatric non-transported patients in Victoria,...

Examining the impact of a symptom assessment application on patient-physician interaction among self-referred walk-in patients in the emergency department (AKUSYM): study protocol for a multi-center, randomized controlled, parallel-group superiority trial

BackgroundDue to the increasing use of online health information, symptom checkers have been developed to provide an individualized assessment of health complaints and provide potential diagnoses and an urgency estimation. It is assumed that they support patient empowerment and have a positive impact on patient-physician interaction and satisfaction with care. Particularly in the emergency department (ED), symptom checkers could be integrated to bridge waiting times in the ED, and patients as well as physicians could take advantage of potential positive effects. Our study therefore aims to assess the impact of symptom assessment application (SAA) usage compared to no SAA usage on the patient-physician interaction in self-referred walk-in patients in the ED population.MethodsIn this multi-center, 1:1 randomized, controlled, parallel-group superiority trial, 440 self-referred adult walk-in patients with a non-urgent triage category will be recruited in three EDs in Berlin. Eligible participants in the intervention group will use a SAA directly after initial triage. The control group receives standard care without using a SAA. The primary endpoint is patients’ satisfaction with the patient-physician interaction assessed by the Patient Satisfaction Questionnaire.DiscussionThe results of this trial could influence the implementation of SAA into acute care to improve the satisfaction with the patient-physician interaction.Trial registrationGerman Clinical Trials Registry DRKS00028598. Registered on 25.03.2022

The Association Between Problematic Use of Alcohol and Drugs and Repeat Self-Harm and Suicidal Ideation.

Aims: We investigated the association between problematic use of alcohol and/or drugs (PUAD) and the incidence, urgency, and mode of discharge for a subsequent episode of self-harm (SH) or suicidal ideation (SI). Methods: This was a retrospective population-based cohort study of individuals admitted to hospital for an index episode of SH/SI (2010-2014) using linked data from hospital admissions and emergency department (ED) presentations. The outcome variables were (1) subsequent presentation to the ED for SH/SI, (2) triage category, and (3) mode of departure. Key predictors were PUAD. Results: In total, 23,007 individuals were admitted to hospital for an index SH/SI, of whom 8% had a subsequent presentation to an ED for SH/SI within a year. The odds of subsequent presentation was increased in those with problematic alcohol use (AOR 1.62, 95% CI 1.36, 1.92), drug use (AOR 1.28, 95% CI 1.07, 1.53), and mental health diagnoses (AOR 1.63, 95% CI 1.44, 1.85). Those with problematic alcohol use were more likely to be assigned to the most urgent triage categories (AOR 1.84, 95% CI 1.32, 2.56). Limitations: Defining SH and PUAD using administrative data is challenging, and the true prevalence is likely to be underestimated. Conclusion: The findings underscore the importance of drug health intervention as a key component of self-harm prevention.

Impact of COVID-19 Pandemic on Emergency Department Volume and Acuity in Low Incidence Area: Taiwan's Experience in Three Hospitals.

The decrease in emergency department (ED) patient visits during the COVID-19 pandemic was reported by various studies. Our study aimed to investigate whether a similar trend can be observed in a country with a low incidence of COVID-19 as well as the impact caused by the pandemic on ED patients in different triage levels and categories. This multicenter retrospective study collected data from three regional hospitals between March 2019 and December 2020. We evaluated the differences between patient volume, disease severity, and patient composition in ED before and after the COVID-19 pandemic among these hospitals. There was a 23% reduction in ED patient volume in the urban hospital (hospital A) as well as a 16% reduction in suburban hospitals (hospitals B and C) during the pandemic period, respectively. The regression analysis showed a high correlation in the change in monthly patient volume among these hospitals. In terms of severity, there was a 24% reduction in ED visits with high severity levels (Taiwan Triage and Acuity Scale [TTAS] I, II) in hospital A, as well as 16% and 12% in hospitals B and C during the pandemic period, respectively. Similarly, there was a 23% reduction in ED visits with low severity levels (TTAS III, IV, V) in hospital A, as well as 20% and 16% in hospitals B and C during the pandemic period, respectively. In terms of patient types, there was a significant decline in non-traumatic adult patients (19%, 17%, and 10%), and pediatric patients (49%, 50%, and 46%) in hospitals A, B, and C, respectively. Despite the low incidence of COVID-19 in Taiwan, a decrease in total ED visits was still found during the pandemic, especially in non-trauma adult visits and pediatric visits. In addition, ED visits in both high and low severity levels decreased in these regional hospitals.

Comparison of Satisfaction Levels between COVID-19 and Non-COVID-19 Patients in the Emergency Department

Background: Patient satisfaction in the emergency department is an indicator of the quality of healthcare service provided. The increased workload and stress of healthcare workers due to the ongoing pandemic can affect the quality of patient care and thus patient satisfaction. This study compares the satisfaction levels of COVID-19 and non-COVID-19 patients in the emergency department. &#x0D; Tools and Methods: In this prospective, observational survey study, the brief emergency patient satisfaction scale (BEPSS) was used to establish the satisfaction levels of patients.&#x0D; Results: Satisfaction levels were significantly higher, while waiting times were quite shorter for COVID-19 patients than for non-COVID-19 patients. The triage categories had no effect on the satisfaction of non-COVID-19 patients, while satisfaction levels were significantly lower in patients with green triage tags than in those with yellow and red triage tags among the COVID-19 patients.&#x0D; Conclusion: The satisfaction levels of COVID-19 patients were higher than those of non-COVID-19 patients. The short waiting times for COVID-19 patients in the emergency department have a significant impact on patient satisfaction.

Characteristics of First Nations patients who take their own leave from an inner-city emergency department, 2016-2020.

Using a strength-based framework, we aimed to describe and compare First Nations patients who completed care in an ED to those who took their own leave. Routinely collected adult patient data from a metropolitan ED collected over a 5-year period were analysed. A total of 6446 presentations of First Nations patients occurred from 2016 to 2020, constituting 3% of ED presentations. Of these, 5589 (87%) patients waited to be seen and 857 (13%) took their own leave. Among patients who took their own leave, 624 (73%) left not seen and 233 (27%) left at own risk after starting treatment. Patients who were assigned a triage category of 4-5 were significantly more likely to take their own leave (adjusted odds ratio [OR] 3.17, 95% confidence interval [CI] 2.67-3.77, P < 0.001). Patients were significantly less likely to take their own leave if they were >60 years (adjusted OR 0.69, 95% CI 1.01-1.36, P=0.014) and had private health insurance (adjusted OR 0.61, 95% CI 0.45-0.84, P < 0.001). Patients were more likely to leave if they were women (adjusted OR 1.17, 95% CI 1.01-1.36, P=0.04), had an unknown housing status (adjusted OR 1.76, 95% CI 1.44-2.15, P < 0.001), were homeless (adjusted OR 1.50, 95% CI 1.22-1.93, P < 0.001) or had a safety alert (adjusted OR 1.60, 95% CI 1.35-1.90, P < 0.001). A lower triage category is a strong predictor of First Nations patients taking their own leave. It has been documented that First Nations patients are under-triaged. One proposed intervention in the metropolitan setting is to introduce practices which expediate the care of First Nations patients. Further qualitative studies with First Nations patients should be undertaken to determine successful approaches to create equitable access to emergency healthcare for this population.

Nationwide study of the characteristics of frequent attenders with multiple emergency department attendance patterns

The burden of frequent attenders (FAs) of emergency departments (EDs) on healthcare resources is underestimated when single-centre analyses do not account for utilisation of multiple EDs by FAs. We aimed to quantify the extent of multiple ED use by FAs and to characterise FAs. We reviewed nationwide ED attendance in Singapore data from 1 January 2006 to 31 December 2018 (13 years). FAs were defined as patients with ≥4 ED visits in any calendar year. Single ED FAs and multiple ED FAs were patients who attended a single ED exclusively and ≥2 distinct EDs within the year, respectively. Mixed ED FAs were patients who attended a mix of a single ED and multiple EDs in different calendar years. We compared the characteristics of FAs using multivariable logistic regression. We identified 200,130 (6.3%) FAs who contributed to1,865,704 visits (19.6%) and 2,959,935 (93.7%) non-FAs who contributed to 7,671,097 visits (80.4%). After missing data were excluded, the study population consisted of 199,283 unique FAs. Nationwide-linked data identified an additional 15.5% FAs and 29.7% FA visits, in addition to data from single centres. Multiple ED FAs and mixed ED FAs were associated with male sex, younger age, Malay or Indian ethnicity, multiple comorbidities, median triage class of higher severity, and a higher frequency of ED use. A nationwide approach is needed to quantify the national FA burden. The multiple comorbidities and higher frequency of ED use associated with FAs who visited multiple EDs and mixed EDs, compared to those who visited a single ED, suggested a higher level of ED burden in these subgroups of patients. The distinct characteristics and needs of each FA subgroup should be considered in future healthcare interventions to reduce FA burden.

Presentations of children to emergency departments across Europe and the COVID-19 pandemic: A multinational observational study.

During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses. Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes. Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems. Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell. ISRCTN91495258 https://www.isrctn.com/ISRCTN91495258.

Investigation into the predictive capability for mortality and the trigger points of the National Early Warning Score 2 (NEWS2) in emergency department patients

IntroductionNational Early Warning Score 2 (NEWS2) is widely used to monitor and trigger assessment throughout a patient’s hospital journey. Since the development and role out of NEWS2, its ability to...

Health Information Seeking From an Intelligent Web-Based Symptom Checker: Cross-sectional Questionnaire Study

BackgroundThe ever-growing amount of health information available on the web is increasing the demand for tools providing personalized and actionable health information. Such tools include symptom checkers that provide users with a potential diagnosis after responding to a set of probes about their symptoms. Although the potential for their utility is great, little is known about such tools’ actual use and effects.ObjectiveWe aimed to understand who uses a web-based artificial intelligence–powered symptom checker and its purposes, how they evaluate the experience of the web-based interview and quality of the information, what they intend to do with the recommendation, and predictors of future use.MethodsCross-sectional survey of web-based health information seekers following the completion of a symptom checker visit (N=2437). Measures of comprehensibility, confidence, usefulness, health-related anxiety, empowerment, and intention to use in the future were assessed. ANOVAs and the Wilcoxon rank sum test examined mean outcome differences in racial, ethnic, and sex groups. The relationship between perceptions of the symptom checker and intention to follow recommended actions was assessed using multilevel logistic regression.ResultsBuoy users were well-educated (1384/1704, 81.22% college or higher), primarily White (1227/1693, 72.47%), and female (2069/2437, 84.89%). Most had insurance (1449/1630, 88.89%), a regular health care provider (1307/1709, 76.48%), and reported good health (1000/1703, 58.72%). Three types of symptoms—pain (855/2437, 35.08%), gynecological issues (293/2437, 12.02%), and masses or lumps (204/2437, 8.37%)—accounted for almost half (1352/2437, 55.48%) of site visits. Buoy’s top three primary recommendations split across less-serious triage categories: primary care physician in 2 weeks (754/2141, 35.22%), self-treatment (452/2141, 21.11%), and primary care in 1 to 2 days (373/2141, 17.42%). Common diagnoses were musculoskeletal (303/2437, 12.43%), gynecological (304/2437, 12.47%) and skin conditions (297/2437, 12.19%), and infectious diseases (300/2437, 12.31%). Users generally reported high confidence in Buoy, found it useful and easy to understand, and said that Buoy made them feel less anxious and more empowered to seek medical help. Users for whom Buoy recommended “Waiting/Watching” or “Self-Treatment” had strongest intentions to comply, whereas those advised to seek primary care had weaker intentions. Compared with White users, Latino and Black users had significantly more confidence in Buoy (P<.05), and the former also found it significantly more useful (P<.05). Latino (odds ratio 1.96, 95% CI 1.22-3.25) and Black (odds ratio 2.37, 95% CI 1.57-3.66) users also had stronger intentions to discuss recommendations with a provider than White users.ConclusionsResults demonstrate the potential utility of a web-based health information tool to empower people to seek care and reduce health-related anxiety. However, despite encouraging results suggesting the tool may fulfill unmet health information needs among women and Black and Latino adults, analyses of the user base illustrate persistent second-level digital divide effects.

An illicit drug early warning system in Victoria, Australia: The role of forensic toxicology in clinical casework

In response to the evolving threat of illicit substance use in Australia, public health bodies and advisory committees have called for an enhanced public health response including greater visibility related to community illicit drug use, particularly novel psychoactive substances (NPS). Victorian state government agencies recommended the development of a state-wide illicit drug early warning system (EWS), utilising data-sharing collaborations between emergency physicians, forensic laboratories, researchers, and health services. Current monitoring modalities utilised in Australia, such as surveys, wastewater monitoring and coronial investigations, lack the specificity and/or responsiveness required for an effective EWS. Clinical toxicity observed in patients presenting to emergency departments (EDs) following exposure to an illicit drug provides an objective and timely measure of harm. Although illicit drug EWS exist in other jurisdictions, not all utilise high-quality forensic analysis and instead rely on patient-reported exposure. However, there is evidence demonstrating poor correlation between reported exposure and forensic analytical findings. The Emerging Drugs Network of Australia Victoria (EDNAV) was therefore created to provide a clinical registry collecting high-quality clinical and analytical data from Emergency Department (ED) illicit drug presentations, combined with a multi-disciplinary expert team to analyse registry data and provide intelligence to a state illicit drug EWS. The EDNAV is a Human Research Ethics Committee (HREC) approved project created in conjunction with a pilot project utilising data from wastewater analysis, syringe residue analysis and ED illicit drug presentations to provide health authorities with intelligence on community drug use. Patients 16 years of age or older presenting to one of eleven EDNAV project EDs with reported or suspected illicit drug related toxicity requiring a venipuncture as part of their standard clinical care are eligible for registry inclusion. Blood samples from cases are transferred weekly to the Victorian Institute of Forensic Medicine (VIFM) Toxicology Department. Overnight liquid chromatography-tandem mass spectrometry (LC-MS/MS) screens for 327 common pharmaceuticals and illicit substances (including ∼80 NPS), followed by a secondary NPS specific screen targeting 268 NPS. The NPS specific screen is actively updated based on emerging drug intelligence and literature reports. The HREC approved waiver of patient consent to include deidentified clinical and analytical data into a purpose built secure on-line (REDCap platform) registry. Forensic and clinical toxicologists/emergency physicians produce intelligence reports based on EDNAV registry data, which are provided to department of health policy officers to identify triggers and/or threats that lead to interventions designed to reduce community harm. There were 700 ED illicit drug presentations included in the EDNAV registry during the period September 2020–February 2022 (71% male, median age 33 years). Eighty-seven percent of patients arrived in ED via ambulance. Overall clinical acuity was high with 22% Australasian triage category 1 (require immediate treatment), and 62% category 2 (require treatment within 10 minutes), while 47% of patients were classified as having moderate, and 41% severe clinical toxicity. In additional to traditional illicit substances, novel substance detections included illicit benzodiazepines ( n = 10), cathinones ( n = 9), synthetic cannabinoid receptor agonists ( n = 6), and opioids ( n = 3). Forensic analyses revealed that in over 90% of cases there were different and/or additional drugs detected in comparison to the reported exposure, suggesting significant drug adulteration, drug substitution or under-reporting and highlighting the potential limitations of illicit drug EWS that do not utilise high-quality forensic analysis. Three public health alerts have been released in Victoria as the result of EDNAV registry intelligence, involving detections of N-ethylpentylone, 25B-NBOH, and paramethoxymethamphetamine. The EDNAV registry project has highlighted the critical role of a high-quality forensic analytical service in an illicit drug EWS in the state of Victoria.

Multi-disciplinary community respiratory team management of patients with chronic respiratory illness during the COVID-19 pandemic

The Greater Glasgow & Clyde NHS Trust Community Respiratory Response Team was established to manage patients with chronic respiratory disease at home during the COVID-19 pandemic. The team aimed to avert hospital admission while maximally utilising remote consultations. This observational study analysed outcomes of the triage pathway used, use of remote consultations, hospital admissions and mortality among patients managed by the team. Patients’ electronic health records were retrospectively reviewed. Rates of emergency department attendance, hospital admission and death within 28 days of referral were compared across triage pathways. Segmented linear regression was carried out for emergency admissions in Greater Glasgow and Clyde pre- and post- Community Respiratory Response Team implementation, using emergency admissions for chronic obstructive pulmonary disease in the rest of Scotland as control and adjusting for all-cause emergency admissions. The triage category correlated with hospital admission and death. The red pathway had the highest proportion attending the emergency department (21%), significantly higher than the amber and green pathways (p = 0.03 and p = 0.004, respectively). The highest number of deaths were in the blue “end-of-life” pathway (p < 0.001). 87% of interactions were undertaken remotely. Triage severity appropriately led to targeted home visits. No nosocomial COVID-19 infections occurred among patients or staff. The Community Respiratory Response Team was associated with a significant decrease in emergency admissions (RR = 0.96 for each additional month under the Poisson model) compared to the counterfactual if the service had not been in place, suggesting a benefit in reducing secondary care pressures. The Community Respiratory Response Team effectively managed patients with chronic respiratory disease in the community, with an associated reduction in secondary care pressures during the COVID-19 pandemic.

WE7.9 Triage in Terror-Related Major Incidents

Abstract Introduction Recent major incidents (MI) in the UK have involved intentional explosions or indiscriminate attacks by perpetrators with bladed weapons. At a MI, on-scene triage vitally identifies those needing time-critical surgery and/or resuscitation (Priority 1, or P1, casualties), facilitating urgent transfer to specialist care. Currently, the National Ambulance Resilience Unit (NARU) Triage Sieve is used. We interrogated the Trauma Audit and Research Network (TARN) registry to compare performance of MI triage tools in predicting P1 status amongst adults. Methods TARN patients aged ≥16 years with penetrating and blast injury (January 2008-December 2017) were assigned triage categories (P1, P2, P3, Expectant or Dead) using pre-defined, intervention-based criteria. Ten MI triage tools were applied to patients’ first pre-hospital observations. Tool-predicted and intervention-based P1 assignments were compared. Results Of 5,660 patients, 5,635 (92%) suffered penetrating injuries, 25 (0.4%) sustained blast injuries. Mortality was 3.1% (n=171); median Injury Severity Score was 9 (IQR 9–16). 2,639 (46.6%) patients fulfilled P1 criteria: 1,170 (44.3%) required life-saving and 209 (7.9%) required limb-salvage surgery within 4 hours. The NARU Triage Sieve demonstrated sensitivity of 32.2%, over-triage 40.3% and AUC 0.566 (95%CI 0.555–0.578). The tool best-able to identify P1 casualties was the Battlefield Casualty Drills (BCD) Triage Sieve (sensitivity 68.0%, over-triage 47.3%, AUC 0.573 [95%CI 0.561–0.586]). Conclusions Terrorist attacks characteristically yield a high proportion of patients requiring urgent surgery. The current UK MI triage tool in use, the NARU Triage Sieve, exhibits unacceptably low detection of P1 casualties; we recommend it is superseded by the BCD Triage Sieve.

Patient-reported orofacial-dental pain severity and tele-triage decisions during COVID-19 pandemic: Does the severity of pain drive tele-triage decisions?

BackgroundGlobally, with the COVID-19 pandemic, dental services were limited to emergency/ urgent conditions and were provided only after tele-triage referral for face-to-face management. However, no previous research explored whether the pain severity (PS) drives the tele-triage decisions. The current study examined the association between PS and tele-triage decision of whether to manage the condition remotely or refer the caller for face-to-face management.MethodsThis retrospective cross-sectional study analyzed the PS reported by hotline callers, using numerical rating scale (NRS-11), during the first wave of COVID-19 lockdown (23 March–31 August 2020) and its association with tele-triage decision controlling for age, sex, history of chronic illness, and dental discipline needed. Binomial logistic regression assessed the association between the PS (exposure) and tele-triage decision (outcome). ANOVA compared PS across tele-triage categories, dental history and tentative diagnosis.ResultsPS was significantly associated with tele-triage decisions (p < 0.05). An increase in pain score by 1 unit was associated with 1.4 times increased odds of face-face referral (95% CI: 1.26–1.54). Pediatric/ adolescent patients (9–18 years) (odds ratio (OR) = 2.07; 95% CI: 1.07–4.02), history of chronic illness (OR = 2.12; 95% CI:1.28–3.51), need for surgical specialty (OR = 1.93; 95% CI: 1.22–3.04) and orthodontic specialty (OR = 7.02; 95% CI: 3.54–13.87) were independently associated with tele-triage decision. PS was highest for the emergency triage category (8.00 ± 2.83, P < 0.0001), dental history of tooth with cavity or filling (6.65 ± 2.024, P < 0.0001), and the tentative tele-diagnosis of cellulitis (7.75 ± 2.872, P < 0.0001).ConclusionsDuring COVID-19 pandemic, tele-triage decisions were significantly influenced by patient-reported PS, adjusting for a range of variables. Despite this, referral for face-to-face management was individualized and driven by the tripartite considerations of the reported pain, clinical judgement, and the high transmission characteristics of COVID-19.

Incidence, Trends, and Seasonality of Paediatric Injury-Related Emergency Department Presentations at a Large Level 1 Paediatric Trauma Centre in Australia

This retrospective cohort study aimed to examine the characteristics, incidence, temporal trends, and seasonality of paediatric injury-related Emergency Department (ED) presentations at a large metropolitan paediatric hospital. It included children aged ≤15 years who presented to the ED at The Children’s Hospital at Westmead, Sydney Australia, with a principal diagnosis of injury during the ten-year period from 1 January 2010 to 31 December 2019. Descriptive statistics were used to describe the characteristics of the cohort and the distribution of ED presentations by mode of arrival, triage category, discharge status, injury diagnosis. Negative binomial regression was used to examine percentage change in annual incidence. Seasonality was examined with Seasonal and Trend decomposition using Loess (STL). There were 134,484 (59.7% male children) paediatric injury-related ED presentations during the ten-year period, of which 23,224 (17.3%) were admitted to hospital. Head injury accounted for more than one-quarter (26.8%) of ED presentations. The average annual increase in incidence was more pronounced during the first five years (5.6% [95%CI 4.1% to 7.1%]) than in the last five years (0.8% [95%CI 0.2% to 1.5%]). The monthly incidence of ED presentations had a bimodal distribution with peaks during autumn (March–May) and spring (October–November) seasons. The mean number of ED presentations per day was higher on weekends (40.8 ± 0.3) than weekdays (35.3 ± 0.8). During 2010 to 2019, there was a significant increase in the annual incidence of injury-related ED presentations for children aged ≤15 years, with head injury accounting for more than one-quarter of the ED presentations. The incidence of paediatric injury-related ED presentations was higher during autumn and spring seasons and at weekends. These data will inform health resource planning and priority-setting and advocacy for child injury prevention strategies in Australia.

Associations between elevated high-sensitive cardiac troponin t and outcomes in patients with acute abdominal pain.

The purpose of this study was to determine outcomes in patients presenting to emergency department (ED) with acute abdominal pain and suspected occult myocardial injury [OMI (high-sensitive cardiac troponin T, hs-cTnT level > 14ng/L)] without clinical signs of myocardial ischaemia. We hypothesized that OMI is a common entity associated with poor outcomes. After institutional research ethics committee approval, a retrospective review was performed on patients subjected to extended use of hs-cTnT measurements during two months period in patients admitted to ED with a chief complaint of abdominal pain, aged 30years or older and triaged to red, orange, or yellow categories. Primary outcomes were 30-day, six-month, and one-year mortality, respectively. Adjusted mortality rates were compared using the Cox proportional hazard regression model. Overall, 1000 consecutive patients were screened. A total of 375 patients were subjected to hs-cTnT measurement and 156 of them (41.6%) experienced OMI. None of the patients had acute myocardial infarction diagnosed in the ED. Patients with OMI had a significantly higher 30-day, six-month and one-year mortality compared to the normal hs-cTnT level group [12.8% (20/156) vs. 3.7% (8/219), p = 0.001, 34.0% (53/156) vs. 6.9% (15/219), p < 0.001 and 39.1% (61/156) vs. 9.1 (20/219), p < 0.001, respectively]. OMI was an independent risk factor for mortality at every time point analyzed. Our investigation noted OMI in older patients with co-morbidities and in higher triage category presenting with abdominal pain to ED, respectively. OMI is an independent risk factor for poor outcomes that warrants appropriate screening and management strategy. Our results support the use of hs-cTnT as a prognostication tool in this subgroup of ED patients.

Development of a low-dimensional model to predict admissions from triage at a pediatric emergency department.

ObjectivesThis study aims to develop and internally validate a low‐dimensional model to predict outcomes (admission or discharge) using commonly entered data up to the post‐triage process to improve patient flow in the pediatric emergency department (ED). In hospital settings where electronic data are limited, a low‐dimensional model with fewer variables may be easier to implement.MethodsThis prognostic study included ED attendances in 2017 and 2018. The Cross Industry Standard Process for Data Mining methodology was followed. Eligibility criteria was applied to the data set, splitting into 70% train and 30% test. Sampling techniques were compared. Gradient boosting machine (GBM), logistic regression, and naïve Bayes models were created. Variables of importance were obtained from the model with the highest area under the curve (AUC) and used to create a low‐dimensional model.ResultsEligible attendances totaled 72,229 (15% admission rate). The AUC was 0.853 (95% confidence interval [CI], 0.846–0.859) for GBM, 0.845 (95% CI, 0.838–0.852) for logistic regression and 0.813 (95% CI, 0.806–0.821) for naïve Bayes. Important predictors in the GBM model used to create a low‐dimensional model were presenting complaint, triage category, referral source, registration month, location type (resuscitation/other), distance traveled, admission history, and weekday (AUC 0.835 [95% CI, 0.829‐0.842]).ConclusionsAdmission and discharge probability can be predicted early in a pediatric ED using 8 variables. Future work could analyze the false positives and false negatives to gain an understanding of the implementation of these predictions.

Postoperative Overtriage to an Intensive Care Unit Is Associated With Low Value of Care.

We test the hypothesis that for low-acuity surgical patients, postoperative intensive care unit (ICU) admission is associated with lower value of care compared with ward admission. Overtriaging low-acuity patients to ICU consumes valuable resources and may not confer better patient outcomes. Associations among postoperative overtriage, patient outcomes, costs, and value of care have not been previously reported. In this longitudinal cohort study, postoperative ICU admissions were classified as overtriaged or appropriately triaged according to machine learning-based patient acuity assessments and requirements for immediate postoperative mechanical ventilation or vasopressor support. The nearest neighbors algorithm identified risk-matched control ward admissions. The primary outcome was value of care, calculated as inverse observed-to-expected mortality ratios divided by total costs. Acuity assessments had an area under the receiver operating characteristic curve of 0.92 in generating predictions for triage classifications. Of 8592 postoperative ICU admissions, 423 (4.9%) were overtriaged. These were matched with 2155 control ward admissions with similar comorbidities, incidence of emergent surgery, immediate postoperative vital signs, and do not resuscitate order placement and rescindment patterns. Compared with controls, overtraiged admissions did not have a lower incidence of any measured complications. Total costs for admission were $16.4K for overtriage and $15.9K for controls ( P =0.03). Value of care was lower for overtriaged admissions [2.9 (2.0-4.0)] compared with controls [24.2 (14.1-34.5), P <0.001]. Low-acuity postoperative patients who were overtriaged to ICUs had increased total costs, no improvements in outcomes, and received low-value care.