Triage Group Research Articles

Screening for distress, the sixth vital sign, in lung cancer patients: effects on pain, fatigue, and common problems—secondary outcomes of a randomized controlled trial

This randomized controlled trial examined the impact of an online routine screening for distress program on physical symptoms and common psychosocial and practical problems in lung cancer outpatients. Patients were randomly assigned to either the minimal screening group (the Distress Thermometer plus usual care); full screening group (Distress Thermometer, Canadian Problem Checklist (CPC), Pain Thermometer, Fatigue Thermometer, and the Psychological Screen for Cancer Part C, with a personalized report summarizing concerns); or triage (full screening plus option of personalized phone triage). Outcomes included pain, fatigue and psychosocial, practical and physical problems. Patients were reassessed 3 months later. A total of 549 lung patients completed baseline measures (89% of eligible patients) and 65.9% were retained at 3 months. At 3 months follow-up, significantly fewer patients in the triage group (32.1%) reported pain compared with the minimal screening group (49.6%), but the triage and full screening groups were not significantly different from one another. Patients in the triage group reported fewer problems with coping compared with the minimal and full screening groups and fewer problems with family conflict compared with the minimal screening group. Full screening patients reported fewer problems with breathlessness compared with the minimal screening group. No differences were found among groups in fatigue. Referrals were not associated with changes in outcomes over time. Routine screening for distress followed by personalized triage resulted in the most benefit for lung patients, with fewer fully screened and triaged patients reporting physical symptoms and psychosocial problems than those only minimally screened.

Comorbidity-polypharmacy score: A novel adjunct in post–emergency department trauma triage

ObjectivePost–emergency department triage of older trauma patients continues to be challenging, as morbidity and mortality for any given level of injury severity tend to increase with age. The comorbidity-polypharmacy score (CPS) combines the number of pre-injury medications with the number of comorbidities to estimate the severity of comorbid conditions. This retrospective study examines the relationship between CPS and triage accuracy for older (≥45y) patients admitted for traumatic injury. MethodsPatients aged 45y and older presenting to level 1 trauma center from 2005 to 2008 were included. Basic data included patient demographics, injury severity score, morbidity and mortality, and functional outcome measures. CPS was calculated by adding total numbers of comorbid conditions and pre-injury medications. Patients were divided into three triage groups: undertriage (UT), appropriate triage (AT), and overtriage (OT). UT criteria included initial admission to the floor or step-down unit followed by an unplanned transfer to intensive care unit (ICU) within 24h of admission. OT was defined as initial ICU admission for <1d without stated need for ICU level of care (i.e., lack of evidence for tracheal intubation or mechanical ventilation, injury-related hemorrhage, or other traditional ICU indications, such as intracranial bleeding). All other patients were presumed to be correctly triaged. The three triage groups were then analyzed looking for contributors to mistriage. ResultsCharts for 711 patients were evaluated (mean age, 63.5y; 55.7% male; mean ISS, 9.02). Of those, 11 (1.55%) met criteria for UT and 14 (1.97%) for OT. The remaining 686 patients had no evidence of mistriage. The three groups were similar in terms of injury severity and GCS. The groups were significantly different with respect to CPS, with UT CPSs (14.9±6.80) being nearly three times higher than OT CPSs (5.14±3.48). There were more similarities between AT and OT groups, with the UT group being characterized by greater number of complications and lower functional outcomes at discharge (all, P<0.05). The UT group had significantly higher mortality (27%) than the AT and OT groups (6% and 0%, respectively). ConclusionsIn the era of medication reconciliation, CPS is easy to obtain and calculate in patients who are not critically injured. This study suggests that CPS may be a promising adjunct in identifying older trauma patients who are more likely to be undertriaged. The significance of our findings is especially important when considering that injury severity in the UT group was similar to that in the other groups. Further evaluation of CPS as a triage tool in acute trauma is warranted.

First Medical Contact to Balloon Time – The Impact of Field 12 Lead ECG

Background: A door to balloon time (D2BT) of less than 90 min is a popular metric to measure efficiency of STEMI treatment with PCI. With the advent of pre-hospital thrombolysis, first medical contact to balloon, or needle, time (FMC2BT) is gaining popularity as the optimal metric in assessing systems of care in STEMI, with a FMC2BT of less than 90 min advocated. Aims: To investigate the effect of field 12 lead ECG to triage STEMI on FMC2BT. Methods and results: We performed a prospective interventional study involving 175 patients undergoing primary PCI who presented to a single health care network in 2011. The D2BT and FMC2BT of all patients (n = 97) who underwent PPCI following field ECG was compared to a contemporary group of 78 patients undergoing PPCI but not receiving field 12 lead ECG triage. The median D2BT of the pre-hospital triage group was 54 min compared to 115 min in the comparator group, P < 0.001.The median FMC2BT in the pre-hospital triage group was 106 min compared to 140 min in the group not receiving pre-hospital ECG (P < 0.001). The proportion of patients who achieved a FMC2BT of ≤90 min was 21.6% in patients receiving pre-hospital triage and 11.5% in the comparator group (P = 0.11). Conclusions: A FMC2BT of less than 90 min is difficult to achieve despite best practice pre-hospital 12 lead ECG triage and rapid hospital based reperfusion.

The South African triage scale (adult version) provides valid acuity ratings when used by doctors and enrolled nursing assistants

To estimate the validity of triage ratings by South African nurses and doctors with training and practical experience using the South African Triage Scale. Five emergency physicians and 10 enrolled nursing assistants, who had been trained in the use of the South African Triage Scale, were selected via convenience sampling to retrospectively triage adult emergency centre vignettes. Participants independently assigned triage ratings to 100 written vignettes unaware of the ratings given by others. Triage ratings were compared with ratings of two experts from the South African Triage Group. Standard validity indicators including sensitivity, specificity, positive predictive value and negative predictive value were used to estimate the validity for the combined group of emergency physicians and enrolled nursing assistants. Associated percentages for over-/under-triage were used to further assess validity within the South African context and over-/under-prediction to further assess practical application of the South African Triage Scale. On average over all acuity levels, sensitivity was 75%, specificity 91%, under-triage occurred 10% and over-triage 15% of the time. The positive predictive value was 74% and negative predictive value 91%. The results of this study fall within the accepted range of over-/under-triage and indicate that the South African Triage Scale is valid when used by emergency physicians and nurses to triage emergency centre vignettes under South African conditions. Further research into appropriate reference ranges for extent of over-/under-triage and over-/under-prediction within each acuity level is recommended. Estimer la validité des taux de triage effectués par des infirmiers et médecins sud-africains disposant d'une formation et d'une expérience pratique dans l'utilisation de l’échelle de triage sud-africaine. Cinq médecins urgentistes et 10 aides-soignants inscrits, formés à l'utilisation de l’échelle de triage sud-africaine, ont été sélectionnés au moyen d'un échantillonnage de commodité afin de trier rétrospectivement les vignettes d'un centre d'urgence pour adultes. Les participants ont indépendamment assigné des taux de triage à 100 vignettes écrites, sans connaître les taux attribués par les autres. Les taux de triage ont été comparés aux taux de deux experts du Groupe de triage sud-africain. Des indicateurs de validité standard, comme la sensibilité, la spécificité, la valeur prédictive positive et la valeur prédictive négative, ont été utilisés afin d'estimer la validité pour l'intégralité du groupe constitué par les médecins urgentistes et les aides-soignants inscrits. Des pourcentages associés pour le sur-/sous-triage ont été utilisés afin d’évaluer de manière plus approfondie la validité dans le contexte sud-africain, ainsi que pour la sur-/sous-prédiction afin d’évaluer de manière plus approfondie l'application pratique de l’échelle de triage sud-africaine. En moyenne sur tous les niveaux d'acuité, la sensibilité était de 75 %, la spécificité de 91 %, un sous-triage se produisait 10 % du temps et un sur-triage 15 % du temps. La valeur prédictive positive était de 74 % et la valeur prédictive négative était de 91 %. Les résultats de cette étude sont compris dans la fourchette acceptée de sur-/sous-triage et indiquent que l’échelle de triage sud-africaine est valide lorsqu'elle est utilisée par des médecins urgentistes et des infirmiers pour trier les vignettes d'un centre d'urgence dans des conditions sud-africaines. Il est recommandé de procéder à une étude supplémentaire des fourchettes de référence appropriées afin de mesurer l'ampleur du sur-/sous-triage et de la sur-/sous-prédiction à chaque niveau d'acuité.

Pre-hospital ECG in patients undergoing primary percutaneous interventions within an integrated system of care: reperfusion times and long-term survival benefits

Treatment delay is a powerful predictor of survival in STEMI patients undergoing primary PCI. We investigated the effectiveness of pre-hospital triage with direct referral to PCI, alongside more conventional referral strategies. From January 2003 to December 2007, 1,619 STEMI patients were referred for primary PCI at our cathlab through two main triage groups: i.e., 1) following pre-hospital triage (n=524), 2) via more conventional triages (n=1,095) represented by the S. Orsola-Malpighi hospital emergency department triage (hub hospital) and local hospital triage. Pre-hospital diagnosis was associated with a 76 minute reduction in pain-to-balloon time (143 [107-216] vs. 219 [149-343], p=0.001) allowing mechanical revascularisation within 90 minutes from the first medical contact in the vast majority of the patients (>80%). Clinically, pre-hospital triage showed no significant reductions in terms of adjusted long-term mortality (HR 0.81, 95% CI 0.61-1.08; p=0.16) in the overall population. However, significant adjusted survival benefits were observed in high-risk groups (i.e., cardiogenic shock, TIMI risk score >30, diabetes mellitus). This study shows that pre-hospital diagnosis allows for significant reductions in primary PCI treatment delays and suggests the hypothesis that this referral strategy might provide long-term survival benefits especially in high-risk patients.

Book review

In November 1994, a small group of senior emergency physicians met to consider the triage process in Manchester. As they have become known, the Manchester Triage Group ultimately devised the now muchdocumented Manchester Triage System (MTS) which was first published in 1996. This book documents the newly revised version of that original model.

Effect of Prehospital Triage on Revascularization Times, Left Ventricular Function, and Survival in Patients With ST-Elevation Myocardial Infarction

Shorter reperfusion times lead to better outcomes in patients with ST-elevation myocardial infarction (STEMI). We assessed the efficacy of prehospital triage with bypass of community hospitals and early activation of the cardiac catheterization team on revascularization times, left ventricular (LV) ejection fraction, and survival. Patients with STEMI (624) were divided into 3 groups determined by site of triage: ambulance field triage (163), interventional center emergency department (202), and 3 community hospital emergency departments (259). Compared with community hospital and interventional center triages, ambulance field triage resulted in a significant median decrease in door-to-balloon times of 68 and 27 minutes, respectively (p <0.001). LV ejection fraction was highest in the field triage group (52 +/- 13%) compared with the interventional center (49 +/- 12%) and community hospital (48 +/- 12%, p = 0.017) groups. Thirty-day mortality was lowest in the ambulance field group (3%) compared with the interventional facility (11%) and community hospital (4%, p = 0.007) groups. There was a significant difference in long-term survival with up to 30-month follow-up among the 3 triage groups (p = 0.041). With time-dependent Cox regression modeling the difference in survival was significant only during the first week after STEMI (p = 0.020). Every extra minute of symptom onset to reperfusion time was associated with a relative risk of long-term mortality of 1.003 (95% confidence interval 1.000 to 1.006, p = 0.027). In conclusion, field triage of patient with STEMI decreased revascularization times, which preserved LV function, and improved early survival.

Triage of women with equivocal or low‐grade cervical cytology results: a meta‐analysis of the HPV test positivity rate

Consistent evidence underlines the utility of human papillomavirus (HPV) DNA testing in the management of women with equivocal cervical cytological abnormalities, but not in case of low-grade lesions. We performed a meta-analysis including studies where the high-risk probe of the Hybrid Capture-II is used to triage these two cytological categories. The triage test-positivity rate reflects the colposcopy referral workload.Data were pooled on the HPV test positivity rate in women with atypical squamous cells of undetermined significance (ASCUS/ASC-US) or low-grade squamous intraepithelial lesions (LSIL), derived from different cytological classification systems. The meta-analysis was restricted to studies, published between 1991 and 2007. A random-effect model was applied for meta-analytical pooling and the influence of covariates on the HPV positivity rate was analyzed by meta-regression. The variation by age was assessed within individual studies since age strata were not defined uniformly. On an average, 43% (95% CI: 40–46%) of women with ASCUS/ASC-US were high-risk HPV positive (range 23–74%). In women with LSIL, the pooled positivity rate was 76% (95% CI: 71–81%; range 55–89%). In spite of considerable inter-study heterogeneity, the difference in HPV positivity between the two triage groups was large and highly significant: 32% (95% CI: 27–38%). HPV rates dropped tremendously as age and cutoffs of test positivity increased. Other factors (cytological classification system, country, continent, collection method and year of publication) had no statistically significant impact, except in LSIL triage where HPV positivity was significantly lower in European compared to American studies. Women with LSIL, especially younger women, have high HPV positivity rates suggesting limited utility of reflex HPV triaging these cases. Research is needed to identify more specific methods to triage women with low-grade squamous cervical lesions.

Medicare Expenditures for Nursing Home Residents Triaged to Nursing Home or Hospital for Acute Infection

To compare Medicare payments of nursing home residents triaged to nursing home with those of nursing home residents triaged to the hospital for acute infection care. Observational study with propensity score matching. Fifty-nine nursing homes in Maryland. Two thousand two hundred eighty-five individuals admitted to the 59 nursing homes and followed between 1992 and 1997. Demographic and clinical data were obtained from interviews and medical record review and linked to Medicare payment records. Incident infection was ascertained according to medical record review for new infectious diagnoses or prescription of antibiotics. Hospital triage was defined as hospital transfer within 3 days of infection onset. Hospital triage patients were paired with similar nursing home triage patients using propensity score matching. Medicare expenditures for triage groups were compared in 1997 dollars. Of 3,618 infection cases, 28% were genitourinary infections, 20% skin, 14% upper respiratory, 12% lower respiratory, 4% gastrointestinal, and 2% bloodstream. Two hundred fifty-six pairs of hospital and nursing home triage cases fulfilled matching criteria. Mean Medicare payments+/-standard deviation were $5,202+/-7,310 and $996+/-2,475 per case in the hospital and nursing home triage groups, respectively, for a mean difference of $4,206 (95% confidence interval=$3,260-5,151). Mean payments per case in the hospital triage group were $3,628 higher in inpatient expenditures, $482 higher in physician visit expenditures, $161 higher in emergency department expenditures, and $147 higher in skilled nursing day expenditures. Per-case Medicare expenditures are higher with hospital triage than for nursing home triage for nursing home residents with acute infection. This result may be used to estimate cost savings to Medicare of interventions designed to reduce hospital use by nursing home residents.

A prospective evaluation of the Cape triage score in the emergency department of an urban public hospital in South Africa

Background:Until recently South Africa had no triage system for emergency department (ED) use. The Cape triage group developed a triage scale called the Cape triage score (CTS). This system consists...

Nutritional status of advanced lung cancer patients and its effect on survival

9567 Background: Weight loss and malnutrition are common in patients with non-small cell lung cancer (NSCLC) and have a negative impact on survival. Early detection and intervention may impact positively on quality of life. The Patient Generated Subjective Global Assessment (PG-SGA) is a validated tool for screening nutritional status and triaging cancer patients with a potential score of 36 (Ottery, 2000). Methods: We measured the need for nutritional intervention in 118 newly diagnosed advanced NSCLC outpatients (stages 3B/4) using the PG-SGA score prior to any treatment. Patients were triaged into 4 Nutritional Triage (NT) groups based on Ottery’s recommendations: scores of 0–1 (NT I) required no intervention, 2–3 (NT II) required education, 4–8 (NT III) required intervention by a dietitian and 9 or greater (NT IV) were in critical need of nutritional intervention. We investigated the association between NT groups and weight loss, survival, inflammatory markers (CRP), LDH and albumin. Results: 118 recently diagnosed outpatients (M 63, F 55) aged 64 ± 11.3 years were studied. Patients were triaged into NT I - 21 (18percnt;) pts, NT II - 13 (11percnt;) pts, NT III - 34 (29percnt;) pts and NT IV - 50 (42percnt;) pts. Median PG-SGA score was 7. 76percnt; of pts had 0–5percnt; weight loss in the past month, 10percnt; had a weight loss of 5–10percnt; and 14percnt; had a weight loss >10percnt;. Low albumin, high LDH and high CRP were significantly associated with a higher PG-SGA score (p=0.016, 0.029 and 0.022 respectively). The NT group was significantly associated with survival. Overall median survival was 7.0 months. The median (95percnt; CI) survival of patients in NT groups I, II, III and IV was 12 (CI: 9–16), 10 (CI: 7–13), 8 (CI: 6–10), 4 (CI: 2–6) months respectively, p<0.0001.The amount of weight loss was also significantly associated with survival. Those with <5percnt; weight loss had a survival of 8 (CI: 5–10) mo vs. 5 (CI: 2–9) mo in those with weight loss ≥5percnt;. Conclusions: The need for nutritional intervention in advanced lung cancer patients is very high. There was a significant association between the PG-SGA NT groups and survival. Weight loss alone may not identify patients in need of nutritional intervention. However the weight loss was still discriminatory with respect to survival. The PG-SGA is a simple screening tool for triaging the nutritional needs of patients with advanced lung cancer. No significant financial relationships to disclose.

Identifying high-risk patients for triage and resource allocation in the ED

Five-point triage assessment scales currently used in many emergency departments (EDs) across the country have been shown to be accurate and reliable. We have found the system to be highly predictive of outcome (hospital admission, intensive care unit/operating room admission, or death) at either extreme of the scale but much less predictive in the middle triage group. This is problematic because the middle triage acuity group is the largest, in our experience comprising almost half of all patients. Patients triaged to the 2 highest acuity categories (A and B) have admission/ED death rates of 76% and 43%, respectively. In contrast, the 2 lowest acuity categories (D and E) have admission/ED death rates of 1% or less. The middle category (C), however, has an overall admission/ED death rate of 10%, too high to be comfortable with prolonged delays in the ED evaluation of these patients. We studied this group to determine if easily obtainable clinical factors could identify higher-risk patients in this heterogeneous category. Data were obtained from a retrospective, cross-sectional study of all patients seen in 2001 at an urban academic hospital ED. The main outcome measure for multivariate logistic regression models was hospital admission among patients triaged as acuity C. Acuity C patients who were 65 years or older, presenting with weakness or dizziness, shortness of breath, abdominal pain, or a final diagnosis related group diagnosis of psychosis, were more likely to be admitted than patients originally triaged in category B. These findings suggest that a few easily obtainable clinical factors may significantly improve the accuracy of triage and resource allocation among patients assigned with a middle-acuity score.

Usefulness of Prehospital Triage in Patients With Cardiogenic Shock Complicating ST-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention

We investigated the impact of ambulance-based prehospital triage on treatment delay and all-cause mortality (in hospital and long term) in patients with ST-elevation myocardial infarction (STEMI) complicated by cardiogenic shock referred for primary percutaneous coronary intervention in a prospectively collected registry. During the study period (January 2003 to December 2005), a total of 121 patients was referred for primary percutaneous coronary intervention at our intervention laboratory through 2 main triage groups: (1) after prehospital, ambulance-telemedicine-based triage (42 patients) and (2) by more conventional routes (79 patients) represented by the institutional S. Orsola-Malpighi hospital emergency department triage (44 patients) and spoke hospital triage (35 patients). Total ischemic time was shorter in the prehospital triage (142 minutes, range 106 to 187, vs 212 minutes, range 150 to 366, p = 0.003). Patients with prehospital triage showed a lower rate (29% vs 54%, p = 0.01) of severely depressed (</=35%) left ventricular systolic function and a 68% decrease in in-hospital mortality (9, 21%, vs 36, 46%, odds ratio 0.32, 95% confidence interval 0.14 to 0.77, p = 0.01). In the entire study population, patients revascularized within an optimal time (2 hours from symptom onset or 90 minutes from STEMI diagnosis) showed remarkably low in-hospital mortality (20% and 29%, respectively). At the 1-year follow-up, patients with prehospital triage had a higher survival rate (74% vs 52%, p = 0.019). In conclusion, this study indicates that prehospital triage with direct transportation to the intervention laboratory is associated with shorter treatment delay and better clinical outcome in patients with STEMI complicated by cardiogenic shock.

Patient Expectations of Emergency Department Care: Phase II – A Cross-Sectional Survey

To explore emergency department (ED) patient expectations regarding staff communication with patients, wait times, the triage process and information management. We conducted a cross-sectional English-language telephone survey among patients aged 18 years or older who visited the EDs in the Calgary Health Region in 2002. Survey items were based on a preceding qualitative study. Of the 941 surveys, 837 were analyzed. Patients placed the highest importance on the explanation of test results (96.5%), a description of circumstances that would require the patient to return to the ED (94.4%), the use of plain language (92.1%) and the reason for the tests (90.8%). Seventy-six percent of patients felt that ED staff should update patients every 30 minutes or less, 51.3% expected patients with non-life threatening problems should wait <1 hour, and 58.3% expected that the tests should be done within 1 hour. Almost two-thirds of the patients (64.4%) believed that the most serious patients should be seen first; 59.3% felt that the seriousness of medical concern should be determined by a triage nurse, and 63.9% thought that their personal health records should be immediately available to the emergency physician without their consent. The actual length of stay was significantly longer than expected length of stay for all patient groups, with Canadian Emergency Department Triage and Acuity Scale Levels IV and V patients expecting a shorter wait than patients in more urgent triage groups. Triage level effects on other expectations were not observed. ED patient expectations appear to be similar across all triage levels. Patients value effective communication and short wait times over many other aspects of care. They have expectations for short wait times that are met infrequently and are currently unattainable in many Canadian EDs. Although it may be neither feasible nor desirable to meet all patient expectations, increased focus on wait times and staff communication may increase both ED efficiency and patient satisfaction.

The Cape Triage Score -- a triage system for South Africa.

The Cape Triage Score (CTS) has been derived by the Cape Triage Group (CTG) for use in emergency units throughout South Africa. It can also be used in the pre-hospital setting, although it is not designed for mass casualty situations. The CTS comprises a physiologically based scoring system and a list of discriminators, designed to triage patients into one of five priority groups for medical attention. Three versions have been developed, for adults, children and infants.

Updated Manchester triage system published this month.

The Manchester Triage Group this month publishes an updated version of its internationally renowned system for prioritising emergency care patients.

Performance of the Roche AMPLICOR® Human papillomavirus (HPV) test in prediction of cervical intraepithelial neoplasia (CIN) in women with abnormal PAP smear

Objectives. To assess the performance of a novel PCR-based assay (Roche AMPLICOR® HPV test) in detection of cervical pathology as a part of management for abnormal PAP smear (MAPS) and in women participating in cervical cancer screening. Study design. Altogether, 504 women comprising 270 patients referred for colposcopy due to an abnormal Pap smear and another 234 women participating in cervical cancer screening (tested for comparison) were analyzed for oncogenic (HR) Human papillomavirus (HPV) types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68 using the Roche AMPLICOR® HPV test in cervical samples collected in PreservCyt® liquid media. Colposcopic biopsy and/or LEEP cone biopsy was used as the gold standard in the triage group, while liquid-based cytology (LBC) was the reference test in the screening group. Results. The prevalence of HPV was significantly higher in the MAPS group (65.9%) than in the screening group (31.2%) ( P = 0.0001). There was a poor concordance between the referral PAP and the current LBC, being only moderate in the screening series, ICC (weighted kappa) = 0.291 (95%CI 0.070–0.459) ( P = 0.007), and almost poor in the MAPS Series, with ICC = 0.217 (95%CI 0.04–0.384) ( P = 0.023). AMPLICOR® HPV positivity increased linearly with the increasing grade of cervical lesions. In detecting high-grade (CIN2–3), colposcopy was the most sensitive test (96.5%), very similar to AMPLICOR (95.2%) ( P = 0.731), while LBC with HSIL cutoff was by far the most specific test (99.5%) and showed the highest PPV (96.1%). NPV of colposcopy (97.2%) and AMPLICOR (96.7%) were similar ( P = 0.839). Together with abnormal colposcopy and HSIL cytology, the AMPLICOR® HPV test is a powerful independent predictor of high-grade CIN2–3, and as such suitable to replace cervical cytology in management of women with abnormal PAP test (MAPS). Conclusions. The Roche AMPLICOR® HPV test is comparable to other HPV tests (HCII, PCR) in detecting CIN in MAPS. However, more data are clearly needed on the performance of AMPLICOR test in management of abnormal PAP and particularly as a screening tool.

Team triage improves emergency department efficiency

Objective: To see whether three hours of combined doctor and nurse triage would lead to earlier medical assessment and treatment and whether this benefit would carry on for the rest...

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Cutting-edge Discussions of Management, Policy, and Program Issues in Emergency Care

Early Labour Assessment and Support at Home: A Randomized Controlled Trial

Objective: To compare childbirth outcomes of women prospectively randomized to receive early labour assessment and support either through a home visit or by telephone triage.Methods: Women in early labour, upon seeking prior telephone advice on whether or not they were ready to be admitted to BC Women’s Hospital (as was standard hospital practice), were voluntarily randomized to receive either a home visit by an obstetrical nurse or telephone triage.Results: One hundred seventeen women were randomized to receive home care and 120 to receive telephone triage. Significantly fewer women in the home care group arrived at hospital in the latent stage of labour, compared to women in the telephone triage group (odds ratio [OR], 0.37; 95% confidence interval [CI], 0.19–0.72). Significantly fewer women in the home care group received narcotics (OR, 0.55; 95% CI,0.32–0.96). Differences observed in use of epidural analgesia (OR, 0.64; 95% CI, 0.36–1.16) were not statistically significant. Newborns in the home care group were significantly less likely to be admitted to a level II observation nursery (OR,0.13;95% CI, 0.03–0.60). More women in the home care group would recommend this type of care to a friend (P = 0.001).Conclusion: Our findings suggest an association of early labour assessment at home with both admission to hospital in the active phase of labour and reduction in use of analgesia during labour. Early labour support at home was associated with reduced rates of admission of neonates to a level II observation nursery, possibly secondary to reduced exposure to analgesics. Early labour care at home by hospital-based obstetrical nurses is safe and acceptable to women, and may offer advantages in terms of reduced interventions and more vigorous neonates.