ED Triage Research Articles

71 PEWS Program in the Emergency Department Halves Unanticipated Inhospital Transfers for Respiratory Complaints

Study Objectives:To measure the impact of a program using PEWS, as an admission level of care triage tool in the PED, on unanticipated transfers to a higher level of care in the first 12 hours after admission.Methods: This is an analysis of the years before and after (2008 and 2009) implementation of a PEWS program for patients being admitted with respiratory complaints to a dedicated children's hospital. Chief complaints from ED triage were used to identify all patients presenting with respiratory complaints, and admitted patients were assessed for unanticipated transfer to a higher level of care in the first 12 hours after admission. Demographics were assessed for differences between groups as well. Chi-squared tests for differences in proportions were used.Results: There were 40 unanticipated transfers in 2008 and 24 in 2009 (p<0.05). The distribution of the admissions in 2008 (1052 or 90.8% to Floor; 96 or 8.3% to IMC; 11 or 0.9% to ICU) and 2009 (1316 or 91.5% to Floor; 109 or 7.6% to IMC; 13 or 0.9% to ICU) were not significantly different, indicating patients in 2009 were not routinely over-triaged.Conclusion: Implementation of a program in the PED using PEWS as a triage tool for in-patient admission nearly halved the number of unanticipated transfers to a higher level of care without significantly over-triaging. Study Objectives:To measure the impact of a program using PEWS, as an admission level of care triage tool in the PED, on unanticipated transfers to a higher level of care in the first 12 hours after admission. Methods: This is an analysis of the years before and after (2008 and 2009) implementation of a PEWS program for patients being admitted with respiratory complaints to a dedicated children's hospital. Chief complaints from ED triage were used to identify all patients presenting with respiratory complaints, and admitted patients were assessed for unanticipated transfer to a higher level of care in the first 12 hours after admission. Demographics were assessed for differences between groups as well. Chi-squared tests for differences in proportions were used. Results: There were 40 unanticipated transfers in 2008 and 24 in 2009 (p<0.05). The distribution of the admissions in 2008 (1052 or 90.8% to Floor; 96 or 8.3% to IMC; 11 or 0.9% to ICU) and 2009 (1316 or 91.5% to Floor; 109 or 7.6% to IMC; 13 or 0.9% to ICU) were not significantly different, indicating patients in 2009 were not routinely over-triaged. Conclusion: Implementation of a program in the PED using PEWS as a triage tool for in-patient admission nearly halved the number of unanticipated transfers to a higher level of care without significantly over-triaging.

Benefit of BP Measurement in Pediatric ED Patients.

Introduction. Obtaining blood pressures in pediatric emergency department patients is the standard of care; however, there is little evidence to support its utility. This prospective study assesses the benefit of BP acquisition in patients ≤5 years. Methods. Data were collected by the ED triage nurses on 649 patients in two community hospital EDs. Relationships between abnormal blood pressures and the patients' age, acuity, and calm versus not-calm emotional state were analyzed. Results. There were significant differences in the rate of elevated BPs in the calm and not-calm groups of patients. Overall, one- and two-year-old patients were more likely to have elevated BPs than those in other age groups. Very few patients in the sample had hypotension (1%). There was no relationship between Emergency Severity Index (ESI) acuity level and an abnormal BP. Nineteen percent of calm patients had elevated BPs, with 3.6% of patients in the stage two class of hypertension. Conclusions. There is limited benefit in obtaining BPs in children age of five or less regardless of whether the child is calm or not in ESI acuity levels 3 and 4.

ROMICAT II: More Data Evaluating CT-First for Acute Chest Pain ED Triage

ROMICAT II: More Data Evaluating CT-First for Acute Chest Pain ED Triage

Triage Nurse Prediction of Hospital Admission

Numerous factors affect patient flow in the emergency department. One important factor that has a negative impact on flow is ED patients waiting for an inpatient bed. It currently takes approximately 5 hours from triage to a request for an inpatient bed in our emergency department. Knowledge of patients requiring admission early in their ED evaluation could speed up the process of securing a bed. The objective of this study was to determine if an ED triage nurse (TRN) can determine at triage if a patient will be admitted to an inpatient unit. A secondary objective was to measure the confidence of the TRN prediction. A prospective, non-consecutive study was conducted during an 18-day period in 2010 in a community hospital emergency department treating 76,000 patients. Experienced TRNs were trained in the evaluation tool. Immediately after the initial TRN evaluation, a determination was made in writing by the TRN regarding the likelihood of hospital admission and level of confidence in this decision. Patients who did not enter the emergency department through triage (ambulance) or were younger than 18 years were excluded. A total of 3514 patients approached triage. Of these patients, 1866 were eligible for the study and 1164 (62%) were enrolled. We excluded 25 subjects because of missing data, resulting in 1139 subjects. Missed subjects had the same baseline characteristics. A total of 287 (25.2%) hospital admissions occurred. TRN predicted 217 admissions, with a sensitivity of 75.6% (95% confidence interval [CI] 71.3-79.5) and a specificity of 84.5% (95% CI 83.1-85.8). The TRN reported being extremely confident in the prediction 50.1% of the time. In these cases, the TRN demonstrated an admission sensitivity of 81.6% (95% CI 76.5-85.8) and specificity of 93.1% (95% CI 91.8-94.3). The TRN demonstrated a high sensitivity and specificity in admission prediction at triage and could potentially save many hours in requesting an inpatient bed. This increased efficiency could result in a more rapid ED throughput and decreased ED boarding.

Complex chemical burns following a mass casualty chemical plant incident: How optimal planning and organisation can make a difference

IntroductionFour employees at a chemical plant sustained extensive chemical burns following the explosion of a pipeline containing 100% sulphuric acid. We describe the management of these patients from the initial ED triage through to discharge from hospital in life and limb threatening chemical burns. MethodsFour patients who sustained chemical burns to the torso and extremities are reviewed. Data was retrieved from patient case notes and operating theatre logbooks. ResultsFour patients sustained chemical burns during the blast and were immediately transferred to a local ED where a prompt referral was made to the burns service. All patients were male aged 25–59 years (mean 46.5). Burn size was 2–50% BSA (mean 22.5). Following RFDS transfer to the state burns service two patients required immediate excisional surgery. In these patients the chemical burn involved full thickness skin loss with extensive underlying muscle and neurovascular damage. One patient required immediate above knee amputation of one leg and fascial burn excision of the other. The other patient required fascial burn excision of both legs followed by Integra placement 24h later. Both patients had prolonged hospital stays due to the complex nature of their injuries requiring multiple trips to theatre and lengthy rehabilitation. The two patients with smaller burns had straightforward surgery and an unremarkable recovery. ConclusionEarly communication following this mass casualty incident allowed for organisation of tertiary services and early radical surgery which was life saving. Management lessons were learnt following this mass casualty chemical burn incident.

What makes emergency department patients reduce their alcohol consumption? – A computer-based intervention study in Sweden

This study investigates the effectiveness of a computerized emergency department intervention for alcohol consumption and identifies explanation factors associated with reduced alcohol consumption from risk to non-risk drinking. Patients aged 18-69 years registered at the ED triage answered alcohol-related questions on a touch-screen computer. Follow-up data were collected by means of a postal questionnaire that was mailed to the patients 6 months after their ED visit. There were four independent explanations for reduced alcohol consumption: being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider. 339 patients could be followed up and of these were 97 categorized as risk drinkers at baseline and 45 became non-risk drinker 6 month later. Being motivated to reduce alcohol consumption at baseline, influenced by just visiting the emergency department, considering the alcohol-related feedback information and impact from a health care provider were predictors for change from risk to non-risk drinking 6 months later.

229 Impact of Sex and Ethnicity of Patient and Physician Provider on Pain Medication Usage in Emergency Department Patients With Long Bone Fractures

Timely and appropriate relief of pain has been questioned with prior reports of bias based on ethnicity and sex in the ED. Over the last twenty years, multiple studies have shown that race or ethnicity is a risk factor for oligoanalgesia, or the inadequate prescribing of analgesics for patients in pain. Objectives: to determine if prescriber bias exists in choice of medication and timely dispensing based on physician race and sex and the same factors in that of the injured ED patient with a long bone fracture. Design: Retrospective analysis of our electronic medical record (Azyxxi; Smith, Microsoft®: Redmond, WA) at Tertiary care, Level 1, academic emergency department with 90,000 annual visits. The initial query included adult patients presenting to ED triage between Jan 1, 2004 and October 1, 2009 with long bone extremity fractures but without other distracting diagnoses. The sex and ethnicity of the prescribing physician as well as the type of medication (narcotic or non-narcotic) dispensed in the ED and on discharge were noted, along with the route of administration. 782 patients met inclusion criteria, with 60.7% female and a mean age of 50.9 years (95%CI:44.3-56.8). 191 (26%) patients were identified as White, 562 (79%) as African-American, and 29 (5%) as Hispanic. Physician prescriber ethnicities in the study were as follows 79% male and 55% White, 29% African American and 14% Asian. Across all patient groups, 29.0% received no analgesia in the ED and, 12.4% did not receive any prescription for analgesia upon ED discharge. No statistically significant differences were identified in the management of patients' pain when patients' and physicians' race and sex were taken into account. Type of pain medication prescribed and delay to medication delivery in minutes were independent of the race and sex of patients and physicians. The sexes and races of physicians in relation to those of patients do not influence treatment outcomes in this study, when outcomes are measured in terms of time to medication and type of medication given for the management of pain. In contrast to a number of prior studies outside our institution, there was neither sex nor ethnic bias based on patient characteristics at our institution. And, in a first-time report: The sex and ethnicity of the prescriber showed no trend to bias in narcotic pain analgesia to patients analyzed for sex and ethnicity.

Can Emergency Nurses' Triage Skills Be Improved by Online Learning? Results of an Experiment

Emergency nurses deal with increasing complexity of patients. In 2003 there were over 14 million ED visits in Canada. The Canadian Triage and Acuity Scale (CTAS) is a 5-level system used by ED triage nurses to classify patients. There is a need for standardized training for all triage systems. In an effort to improve access to CTAS training, a 6-week Web-based CTAS workshop was developed. We determined the impact of Web learning on the accuracy of the triage skills of registered nurses (RNs). An experimental method was used in which 132 RNs were randomized to an intervention group (n = 65) or control group (n = 67). All RNs received exactly the same content and learning activities. The experimental group differed from the control group in 3 ways: a mandatory tutorial, awarding of marks for online discussion, and completion of a workplace project. Data were collected using standard instruments, chart audit, and interviews. The Web course provided a standardized and effective educational experience that enhanced emergency nurses' triage accuracy. The mandatory online tutorial, online discussion, and workplace project increased the RNs' preparation for online learning, and these educational methods were successful in transferring triage learning to practice. Web learning can help professionals maintain competency and support professional practice. Further research is needed to provide evidence for best practices in E-learning for RNs. The accuracy of the RN's triage assessment impacts patient health, hospital accreditation, and funding.

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

Oxymetazoline Superior to Cocaine and Lidocaine for Nosebleeds

(A261) Evolution of Triage Services in the Emergency Department Aga Khan University Hospital- Karachi

The history of triage started from the French battle field. In- hospital ED triage started in early 1960's from Baltimore. It is now an essential component of modern ED. Triage is not only to sort out patients as per their criticality, but it also serves the purpose of streamlining the patients so that the patient receives right treatment at the right time in the appropriate area. It helps to manage the ED overcrowding by better flow of patients. AKUH-ER experience of triage dates back to the year 2000, when triage was conducted by physicians and there used to be a manual documentation of patient's particulars such as complaints, vitals and BP. With the expansion of AKU-ED in 2008 responsibility of triage shifted to nursing services. Triage policy was drafted and implemented and for guidance and uniformity of care, triage protocols were developed. Another important development is replacement of register with triage data entry software. This help us to monitor some indicators like number of patients triaged, the time between triaging and actual bed assignment, triage categorization, length of stay, dispositions and return visits. The available information now helps us to make decisions based on evidence and also paves the way for future direction.

Enhancing ED Triage to Accommodate the Special Needs of Geriatric Patients

Enhancing ED Triage to Accommodate the Special Needs of Geriatric Patients

EMF-7: Does an Electronic Medical Record Reminder Improve Triage Protocol Compliance Among Emergency Department Triage Nurses

EMF-7: Does an Electronic Medical Record Reminder Improve Triage Protocol Compliance Among Emergency Department Triage Nurses

198: Screening of Emergency Department Triage Patients Using Near Infrared Spectroscopy

198: Screening of Emergency Department Triage Patients Using Near Infrared Spectroscopy

Characteristics of Patients Who Leave the ED Triage Area Without Being Seen By a Doctor: A Descriptive Study in an Urban Level II Italian University Hospital

In this paper, we describe demographic and clinical features of patients who left the triage area before the visit in the emergency department of Azienda Ospedaliera Universitaria Careggi in 2006. This is a descriptive retrospective study. Data was collected from electronic medical charts. We recorded 45,019 patients who arrived in the emergency department. Of those, 904 left without being seen (2%; Male 51.5%; Female 48.2%). The mean age was 41 years (median 37; range 14-95). We found that this was more common during June and July (114 and 107 cases) and on Mondays (20.5%), with lower rates on Saturdays and Sundays (11.3% and 9%). Two-hundred thirty-nine patients were not Italian. Patients' waiting times before leaving without being seen collected from the nursing notes were recorded in 457 cases (50.5%), and showed a median of 70 minutes (range 0-386). There was a significant difference between this value and the median of waiting times (95 minutes) calculated from the ending time of medical charts in the same group of patients (Wilcoxon Signed Rank Test - P < 0.0001). It confirms the hypothesis that the patients' length of stay before leaving the triage area, gathered from medical charts, isn't reliable because of the delayed ending of charts. After 72 hours from the leave, 17 patients returned. The outcome were: 2 admissions in general ward and 6 new cases of leaving without being seen. There was a prevalence of low-priority triage-level patients compared to the general ED case mix. The rate of patients' leaves follows the indications of Tuscany Region (patients' leaves <5% total ED population).

Effect of Education on a Chest Pain Mnemonic on Door-to-ECG Time

Acute myocardial infarction (AMI) continues to contribute to both death and disability in both men and women. The first step in early intervention is an ECG. Atypically presenting patients, especially those who present by self-transport, are more likely to experience delays. The purpose of this study was to evaluate the effect of a new chest pain mnemonic (CPM) as a teaching tool for rapid recognition of AMI patients arriving by self-transport in ED triage in an effort to improve door-to-ECG (DTE) time. This study is a longitudinal, quasi-experimental quantitative study. Instruction and evaluation of nurses' knowledge related to identification of AMI before and after instruction on the CPM education (intervention) were coordinated by the emergency clinical nurse specialist. The study sample for the educational intervention included 26 nurses (15% of total population) from 4 emergency departments. Ad hoc queries of the National Registry for Myocardial Infarction database for patients arriving by self-transport to the emergency department were done to examine DTE before and after intervention. The pretests and post-tests of the nurses were analyzed with a paired t test, and the pre- and post-intervention DTE times were analyzed by log-linear modeling. Evaluation of nurses' knowledge before and after CPM education indicated an improvement in DTE time, although it was not statistically significant. There was a significant improvement in DTE time for 2 hospitals that was somewhat negated in the aggregate data. There was a noted trend that showed an advantage in DTE time associated with male patients. Inclusion of tools such as the CPM in education programs for emergency nurses improved rapid recognition of AMI patients presenting via self-transport to the emergency department. Attention to gender differences in patient presentation should be included in future CPM education, and tools to assist nurses in the early recognition of AMI need to be developed. Investigation regarding intra-hospital differences is warranted.

Overcrowding in the Emergency Department – Does Volume of Emergency Room Patients Affect Ordering of CT Scans?

CAT scans are among the most expensive, non-invasive tests that can be readily ordered in an Emergency Department. As such it becomes important to understand if there are non-medical factors involved in requesting performance of scans by ED doctors. In an attempt to discern if crowding in the ED or Hospital had any effect on this, data was collected for a six week period in April and May of 2006. After an exhaustive review of the data including a multiple regression analysis no effect of ED or hospital census on scan ordering could be discovered. A minor negative effect (scans were less likely to be positive if it was busy in the ED and the hospital) by a combination of these variables on the percent of scans judged positive was derived.If there are non-medical influences of scan ordering it is does not appear to be crowding. INTRODUCTION AND OBJECTIVES The ease of access and the reliability of results have made use of high technology imaging studies commonplace in hospital emergency departments. However the utilization of expensive resources in hospital emergency departments is becoming an increasing economic problem. Reduction in reimbursements and an increase in the number of uninsured are squeezing the hospital on the financial side while the demand for the tests increases. One question has been whether the tests are being ordered to speed the patient's transit through the emergency room by sending the patient for a test and deferring a thorough history and physical. The doctor or triage nurse can simply say “headache, CAT scan of the brain” or “abdominal pain, CAT scan of the abdomen”. Ultrasound or Doppler scans can be performed just as easily. It is the general impression of radiologists that the vast majority of these studies are nonrevealing. They are either normal or demonstrate findings consistent with the patient's age. It is increasingly disturbing when overlapping tests such as ultrasounds and CAT scans are ordered and they are both negative. There have been many guidelines for ordering of studies published but strict adherence to them is rare. “The ER is all about looking for injury, so the physician’s first inclination is to order imaging to search for it,” one expert has opined as the reason for this mode of practice. If it is true that the ED doctors or triage nurses order more tests when they are squeezed for time and physical resources the number of tests ordered should increase disproportionately with the number of patients seen in the emergency department. It is also possible that hospital crowding could affect ordering of tests in the ED. Patients will wait longer in the ED for a hospital bed when the hospital is full. ED doctors might then order more tests to either discharge the patient quicker or get the patients medical work-up started faster. I have decided to specifically examine head CAT scans. This is a defined exam done for specific purposes and could be easily classified into either abnormal or normal (new normal or normal for age would be considered normal). Correlating hospital and ER census to the number of scans performed or to the rate of abnormal scans might help us determine whether they have been ordered for medical reasons or for functional reasons within the emergency room setting. DATA ANALYSIS AND METHODS Data was obtained for Cedars-Sinai Medical Center for a continuous period from the last three weeks of April through the month of May 2006. The daily census tabulations for the hospital and the Emergency Department were obtained from the hospital (Appendix 1). Head CAT Scans were retrospectively counted on a daily basis from the Imaging Overcrowding in the Emergency Department – Does Volume of Emergency Room Patients Affect Ordering of CT Scans? 2 of 5 Department’s PACs system. They were tabulated for number of studies performed. The reports were examined and classified as either requiring action by a physician or considered normal. Scans were considered positive regardless of whether the findings were pertinent to the indication for the scan or incidental to the admission. (Appendix 2) The findings were than analyzed and examined in several fashions. Ordinary graphs of the daily patterns over the month were obtained and correlations between number of scans ordered and the rate of positives with ED and hospital census were derived. Correlations were calculated in both simple and multiple regression models.

How “Dear SIRS” and MEDS can help for ED triage

Brivet, François G. MD; Jacobs, Frédéric M. MD, AP-HP; Prat, Dominique MD Author Information

A Study of the Workforce for an ED Triage Area in a Tertiary Care Hospital

A Study of the Workforce for an ED Triage Area in a Tertiary Care Hospital

Implementation of the Victorian Emergency Department Mental Health Triage Tool

Summary In 2005, the Department of Human Services (Victoria) commissioned the National Institute of Clinical Studies (NICS) to develop and implement a statewide emergency department triage tool to improve the ED triage processes for mental health presentations to Victorian Emergency Departments. The project was undertaken over a 7-month period from September 2005 to March 2006. This paper describes the implementation approach undertaken by NICS and the outcomes of the project.

The Use of Human Patient Simulation in ED Triage Training Can Improve Nursing Confidence and Patient Outcomes

The Use of Human Patient Simulation in ED Triage Training Can Improve Nursing Confidence and Patient Outcomes