Emergency Department Triage Research Articles

Clinician’s Corner: The Canadian Cervical Spine Rule

A 44-year-old driver of a small sedan self-presents to your emergency department (ED) triage area indicating they developed a stiff neck 30 minutes after they were rear-ended by a small van when they were stopped at a traffic light. The rear bumper of the patient’s vehicle is slightly dented, and there is scuffing to the front bumper of the van. No airbags were deployed and the driver of the sedan did not hit their head. The van was estimated to be travelling between 10-20 km/h at the time of impact. The patient self-extricated from their vehicle and was ambulatory at the scene. Currently, the patient is alert, oriented, and in no distress. The patient denies paresthesia, has no midline cervical spine (c-spine) tenderness, and is able to actively rotate their neck 45° left and right.

Predicting hospital admission from emergency department triage data for patients presenting with fall-related fractures.

Predict in advance the need for hospitalization of adult patients for fall-related fractures based on information available at the time of triage to help decision-making at the emergency department (ED). We developed machine learning models using routinely collected triage data at a regional hospital chain in Pennsylvania to predict admission to an inpatient unit. We considered all patients presenting to the ED for fall-related fractures. Patients who were 18 years or younger, who left the ED against medical advice, left the ED waiting room without being seen by a provider, and left the ED after initial diagnostics were excluded from the analysis. We compared models obtained using triage data (pre-model) with models developed using additional data obtained after physicians' diagnoses (post-model). Our results show good discriminatory power on predicting hospital admissions. Neural network models performed the best (AUC: pre-model = 0.938 [CI 0.920-0.956], post-model = 0.983 [0.974-0.992]). The logistic regression analysis provides additional insights into the data and the relationships between the variables. Using limited data available at the time of triage, we developed four machine learning models aimed at predicting hospitalization for patients presenting to the ED for fall-related fractures. All the four models were robust and performed well. Neural network method, however, performed the best for both pre- and post-models. Simple, parsimonious machine learning models can provide high accuracy for predicting hospital admission.

Impact of the COVID-19 Pandemic on Prenatal Care Utilization at a Public Hospital.

The aim of the study is to compare rates of prenatal care utilization before and after implementation of a telehealth-supplemented prenatal care model due to the coronavirus disease 2019 (COVID-19) pandemic. Using electronic medical record data, we identified two cohorts of pregnant persons that initiated prenatal care prior to and during the COVID-19 pandemic following the implementation of telehealth (from March 1, 2019 through August 31, 2019, and from March 1, 2020, through August 31, 2020, respectively) at Grady Memorial Hospital. We used Pearson's Chi-square and two-tailed t-tests to compare rates of prenatal care utilization, antenatal screening and immunizations, emergency department and obstetric triage visits, and pregnancy complications for the prepandemic versus pandemic-exposed cohorts. We identified 1,758 pregnant patients; 965 entered prenatal care prior to the COVID-19 pandemic and 793 entered during the pandemic. Patients in the pandemic-exposed cohort were more likely to initiate prenatal care in the first trimester (46.1 vs. 39.0%, p = 0.01), be screened for gestational diabetes (74.4 vs. 67.0%, p <0.001), and receive dating and anatomy ultrasounds (17.8 vs. 13.0%, p = 0.006 and 56.9 vs. 47.3%, p <0.001, respectively) compared with patients in the prepandemic cohort. There was no difference in mean number of prenatal care visits between the two groups (6.9 vs. 7.1, p = 0.18). Approximately 41% of patients in the pandemic-exposed cohort had one or more telehealth visits. The proportion of patients with one or more emergency department visits was higher in the pandemic-exposed cohort than the prepandemic cohort (32.8 vs. 12.3%, p < 0.001). Increases in rates of labor induction were also observed among the pandemic-exposed cohort (47.1 vs. 38.2%, p <0.001). Rates of prenatal care utilization were similar before and during the COVID-19 pandemic. However, pregnant persons receiving prenatal care during the pandemic entered care earlier and had higher utilization of certain antenatal screening services than those receiving prenatal care prior to the pandemic. · Patients initiated prenatal care earlier during the COVID-19 pandemic.. · Uptake of telehealth services was low.. · Rates of diabetes screening and ultrasound use increased during the pandemic..

O66 - Evaluation of the implementation of the Birmingham Symptom-specific Obstetric Triage System (BSOTS) in an Australian maternity service

Obstetric triage is usually undertaken by a midwife and involves identifying the woman’s presenting problem and conducting physiological and vital signs assessment. Triage of a pregnant woman poses challenges, as the physiological changes associated with pregnancy do not match the general parameters of standard emergency department triage measures. For these reasons, the Birmingham Symptom-specific Obstetric Triage System (BSOTS) was developed to standardise triage within maternity care. The BSOTS is currently being rolled out in all National Health Service maternity hospitals in the United Kingdom, however our site is the first in Australia to trial this approach. The aim of the study was to evaluate the implementation of the BSOTS in an Australian tertiary maternity service. A mixed-methods approach including surveys, focus groups, and retrospective data audit was undertaken. Participants included midwives and doctors who worked in the Maternity Assessment Centre (MAC) and women who had attended the MAC during the BSOTS implementation. Key outcome measures included: • knowledge and confidence in using BSOTS following the pre-implementation education • time to triage and time to treatment for women in accordance with the BSOTS prioritisation of care • staff experiences and satisfaction of the BSOTS implementation • women’s satisfaction of triage following the BSOTS implementation The findings showed that staff valued the BSOTS standardised approach to maternity triage. The clinical audit showed that women’s time to triage and treatment times were generally being achieved within auditable standards. Almost all women were satisfied with their experience of triage. Lack of knowledge amongst staff (especially medical staff) regarding the approach was perceived to be a barrier to effective implementation. The implementation of the BSOTS demonstrates an innovative midwife led practice change. The BSOTS is applicable to the Australian context, benefiting women, midwives, and the maternity service.

Comparing complaint-based triage scales and early warning scores for emergency department triage

BackgroundEmergency triage systems are used globally to prioritise care based on patients’ needs. These systems are commonly based on patient complaints, while the need for timely interventions on regular hospital...

Advanced Triage Protocol: The Role of an Automated Lactate Order in Expediting Rapid Identification of Patients at Risk of Sepsis in the Emergency Department.

OBJECTIVES:We undertook a process improvement initiative to expedite rapid identification of potential sepsis patients based on triage chief complaint, vital signs, and initial lactate level.DESIGN:Prospective cohort study.SETTING:Seven hundred-bed tertiary care hospital with ≅65,000 patient visits/yr.PATIENTS:Patients presenting to emergency department (ED) triage who met the following criteria: greater than or equal to two of the three systemic inflammatory response syndrome criteria assessable in triage, a chief complaint suggestive of infection, emergency severity index 2 or 3, and ambulatory to ED.INTERVENTIONS:A computer-generated lactate order was created, staff education and resources increased, and point-of-care lactate testing was introduced.MEASUREMENTS AND MAIN RESULTS:Primary endpoints include the following: percent of patients having a lactate level drawn, percent of lactate samples resulting before room placement, and time intervals from triage to lactate blood draw and to lactate result. Secondary endpoints were percentage of patients admitted to the hospital, percentage admitted to the ICU, and in-hospital mortality. Six thousand nine hundred six patients were included: 226 historic controls (HCs) and 6,680 intervention group patients. The mean serum lactate level was 1.77 ± 1.18 mmol/L. The percentage of patients having a lactate resulted increased from 27.4% in the HC period to 79.6%. The percentage of these lactate results available while the patient was still in the waiting room increased from 0.4% during the HC period to 33.7% during Phase 5 (p < 0.0001). In the intervention period, time from triage to lactate result decreased (78.1–63.4 min; p < 0.0001) and time to treatment room decreased (59.3–39.6 min; p < 0.0001).CONCLUSIONS:Implementation of a computerized lactate order using readily available data obtained during ED triage, combined with point-of-care lactate testing, improves time to lactate blood draw and lactate result in patients at risk for severe sepsis. Initial lactate levels correlated with admission to the hospital, admission to the ICU, and in-hospital mortality.

The Accuracy of Sepsis Screening Score for Mortality Prediction at Emergency Department Triage.

IntroductionSepsis has a mortality rate of 10–40% worldwide. Many screening tools for sepsis prediction and for emergency department (ED) triage are controversial. This study compared the accuracy of the scores for predicting 28-day mortality in adult patients with sepsis in the triage area of the ED.MethodsAdult patients who presented to the ED of a tertiary-care university hospital from January–December 2019 with an initial diagnosis of sepsis or other infection-related conditions were enrolled. We calculated predictive scores using information collected in the ED triage area. Prognostic accuracy was measured by the area under the receiver operating characteristic curve (AUROC) for predicting 28-day mortality as a primary outcome. The secondary outcomes included mechanical ventilation usage and vasopressor usage for 28 days.ResultsWe analyzed a total of 550 patients. The 28-day mortality rate was 12.4% (n = 68). The 28-day mortality rate was best detected by the National Early Warning Score (NEWS) (AUROC = 0.770; 95% confidence interval [CI]: 0.705–0.835), followed by the quick Sequential Organ Failure Assessment (qSOFA) score (AUROC = 0.7473; 95% CI: 0.688–0.806), Search Out Severity (SOS) score (AUROC = 0.749; 95% CI: 0.685–0.815), Emergency Severity Index (ESI) triage (AUROC = 0.599; 95% CI: 0.542–0.656, and the Systemic Inflammatory Response System (SIRS) criteria (AUROC = 0.588; 95% CI: 0.522–0.654]). The NEWS also provided a higher AUROC and outperformed for 28-day mechanical ventilator usage and 28-day vasopressor usage.ConclusionThe NEWS outperforms qSOFA, SOS, SIRS, and ESI triage in predicting 28-day mortality, mechanical ventilator, and vasopressor usage of a patient with sepsis who is seen at ED triage.

Developing and Validating an Emergency Triage Model Using Machine Learning Algorithms with Medical Big Data.

ObjectiveTo establish an emergency triage model through the statistical analysis of big data during a particular time period from a hospital information system to improve the accuracy of triage in emergency department (ED).MethodsA total of 276,164 patients who visited the Emergency Medicine Department of Beijing Chao-Yang Hospital from 2017 to 2020 were included in this study, including 123,392 men and 152,772 women aged from 14 to 112 years. The baseline characteristics (age and gender) and medical records (patient’s condition, body temperature, heart rate, breathing, blood pressure, consciousness, and oxygen saturation) of the patients was collected. The data samples were randomly allocated, with 80% as the training set and 20% as the testing set. The patients were divided into levels I, II, III, and IV in accordance with a four-level triage standard. We selected the effective Extreme Gradient Boosting (XGBoost) algorithm as our emergency classification prediction model. The XGBoost model was applied to simulate the thinking process of triage nurses, and the De Long’s test was used to compare the receiver operating characteristic (ROC) curve of different models. The P value was obtained by calculating the variance and covariance of area under the curve (AUC) values of different ROC curves.ResultsLevel I had 4960 (1.8%) patients, level II had 25,646 (9.29%), level III had 130,664 (47.31%), and level IV had 114,894 (41.6%). The XGBoost model was built following a logic exercise based on the traditional manual pre-inspection and triage results. After verification, the prediction accuracy was 82.57%. The AUC of each disease severity level (levels I, II, III, and IV) was 0.9629, 0.9554, 0.9120, and 0.9296, respectively.ConclusionThe emergency triage prediction model, which achieved a relatively strong accuracy rate, can reduce the work intensity of medical workers and improve their working efficiency.

Physician gestalt for emergency department triage: A prospective videotaped study.

Appropriate triage in patients presenting to the emergency department (ED) is often challenging. Little is known about the role of physician gestalt in ED triage. We aimed to compare the accuracy of emergency physician gestalt against the currently used computerized triage process. We conducted a prospective observational study in the ED at an academic medical center. Adult patients aged ≥20 years were included and underwent a standard triage protocol. The patients underwent system-based triage using the computerized software the Taiwan Triage and Acuity Scale. The entire triage process was recorded, and triage data were collected. Five physician raters provided triage levels (physician-based) according to their perceived urgency after reviewing videos. The primary outcome was hospital admission. The secondary outcomes were ED length of stay (EDLOS) and charges. In total, 656 patients were recruited (mean age 52 years, 50% male). The median system-based triage level was 3. By contrast, the median physician-based triage level was 4. The physician raters tended to provide lower triage levels than the system, with an average difference of 1. There was modest concordance between the two triage methods (correlation coefficient 0.30), with a weighted kappa coefficient of 0.18. The area under the receiver operating curve for the system- and physician-based triage in predicting hospital admission were similar (0.635 vs. 0.631, p=0.896). Attending physicians appeared to have better performance than residents in predicting admission. The variation explained (R2 ) in EDLOS and charges were similar between the two triage methods (R2 = 3% for EDLOS, 7%-9% for charges). Emergency physician gestalt for triage showed similar performance to a computerized system; however, physicians redistributed patients to lower triage levels. Physician gestalt has advantages for identifying low-risk patients. This approach may avoid undue time pressure for health care providers and promote rapid discharge.

Investigating racial disparities within an emergency department rapid-triage system

ObjectivesRacial disparities in emergency medical care are abundant, and processes aimed to increase throughput, such as a rapid triage fast-track (FT) systems, may exacerbate these inequities. A FT strategy may be more susceptible to implicit bias as subjective information is obtained quickly. We aim to determine whether a FT model was associated with greater disparities between Black and White emergency department (ED) patients. MethodsTriage-related outcomes were compared across race using a cohort selected from encounters in an ED that uses a FT model. White and Black patient encounters were exact-matched on potential confounders including sex; presence of abnormal vital signs; ED arrival time; insurance type; age category; and chief complaint. The primary triage-related outcome was use of the FT area (versus the main ED), and the secondary outcomes were wait time and assigned encounter acuity. ResultsEncounters for 5151 Black patients were exact-matched with 7179 encounters for White patients. Weights were applied to address differential numbers of encounters from each group. Within this matched cohort, Black patients were more likely to be triaged to FT than White patients (odds ratio = 1.28, 95% CI: 1.12; 1.46) and less likely to be given a high acuity score (odds ratio = 0.73, 95% CI: 0.66, 0.81). Among the high-acuity patients, Black patients were 40% more likely to be triaged to the FT area. ConclusionsThese results suggest that, after controlling for potential confounders, racial disparities may have been exacerbated in a FT ED triage process. In a FT model utilizing physicians and midlevel providers, this may create tiered levels of care between Black and White patients – an unacceptable side-effect of an effort to increase ED throughput.

Association between focused cardiac ultrasound and time to furosemide administration in acute heart failure

BackgroundHeart failure (HF) is a global health burden, and its management in the emergency department (ED) is important. This study aimed to evaluate the association between focused cardiac ultrasound (FoCUS) and early administration of diuretics in patients with acute HF admitted to the ED. MethodsThis retrospective observational study was conducted at a tertiary academic hospital. Patients with acute HF patients who were admitted to the ED and receiving intravenous medication between January 2018 and December 2019 were enrolled. The main exposure was a FoCUS examination performed within 2 h of ED triage. The primary outcome was the time to furosemide administration. ResultsOf 1154 patients with acute HF, 787 were included in the study, with 116 of them having undergone FoCUS. The time to furosemide was significantly shorter in the FoCUS group (median time (q1–q3), 112 min; range, 65–163 min) compared to the non-FoCUS group (median time, 131 min; range, 71–229 min). In the multivariable logistic regression analysis adjusting for age, sex, chief complaint, mode of arrival, triage level, shock status, and desaturation at triage, early administration of furosemide within 2 h from triage was significantly higher in the FoCUS group (adjusted odds ratio, 1.63; 95% confidence intervals, 1.04–2.55) than in the non-FoCUS group. ConclusionsEarly administration of intravenous furosemide was associated with FoCUS examination in patients with acute HF admitted to the ED. An early screening protocol could be useful for improving levels in clinical practice at EDs.

Improving assessments and follow-up for pediatric emergency department mental health visits

Background: Over the past decade, the number of children presenting to emergency departments (ED) with mental health (MH) concerns has increased substantially. EDs struggle to respond to this increase with approaches that comprehensively address patient needs. The lack of standardized processes to perform risk stratification, assess severity, and ensure access to follow-up care pose barriers to the provision of safe MH care. Our team addressed this gap by introducing an evidence-based care bundle to Alberta’s two pediatric EDs. This report presents the quality improvement (QI) approach used to ensure fidelity of implementation at one of the EDs. This initiative was funded by Alberta Innovates (Partnership for Research and Innovation in the Health System; PRIHS).&#x0D; Methods: We used the Model for Improvement to test and implement each bundle element: suicide risk screening (Ask Suicide-Screening Questions [ASQ]) at ED triage; a tool (HEADS-ED) to streamline and standardize MH assessments by ED-based MH nurse); and an urgent, single-session ‘Choice Appointment’ with a MH professional within 96 hours of the ED visit for patients lacking access to appropriate and timely MH follow-up care. The two ED-based bundle elements did not require additional resources or funding and are expected to reduce length of stay. The follow-up clinic option for ED patients without resources is intended to prevent crisis escalation and match patients with supports. Each new practice was introduced sequentially over a 2-week period. For each practice, we identified 1 to 2 improvement aims, developed key driver diagrams, and selected primary outcomes and measures. Each practice was implemented using Plan-Do-Study-Act (PDSA) cycles with initial tests of change starting small and becoming larger as learning accrued from previous cycles. Our QI team included families with lived experience, patient care and unit managers, nurse educators, frontline healthcare providers, content experts, and clinical leaders who supported staff and led change management strategies. A nurse was hired as a QI lead to support execution of PDSA cycles. We developed a sustainability plan which included embedding education regarding new practices in new healthcare staff orientation, having a measurement strategy to ensure that improvement was maintained, and planning for transition of responsibility for these processes to operational and medical leadership. &#x0D; Evaluation Methods: Primary aims included: 80% of targeted patients would receive the ASQ and HEADS-ED and 100% of children eligible for an Urgent, single-session ‘Choice Appointments’ would be offered it within 96 hours. We used clinical data from the electronic health record (Epic/Connect Care) as well as patient experience data collected via parent/caregiver surveys to determine if the aims for each practice were achieved. We included balancing measures to test whether changes in care in one part of the system introduced unintended consequences in other parts. We evaluated results for the primary aims using run charts to rapidly detect change according to established rules for detecting special cause. We discussed the results from each PDSA cycle in the context of existing healthcare resources to support implementation of each element of the bundle.&#x0D; Results: Tests of change to introduce suicide risk screening began February 1st, 2021. Performance was measured in weekly intervals. The median initial use of ASQ by triage nurses was with 77% of MH patients (686/901 patients), and over time, improved to 93% (319/350 patients), with special cause (shift) in noted September 2021. Tests of change to introduce the HEADS-ED tool began February 16th, 2021. Initial use of the HEADS-ED by MH nurses was 81% (440/555) and improved to 87% (201/227) with special cause (shift) noted August 2021. Urgent, single-session ‘Choice Appointments’ were offered to all patients who did not have timely and access to urgent follow-up with an existing mental healthcare provider with 89.1% having an appointment booked within 96 hours of the ED visit (139/156).&#x0D; Advice and Lessons Learned: Three plans were viewed as crucial to the success of this initiative: 1) a robust strategy to develop proposed changes based on best evidence combined with patient and staff engagement; 2) a comprehensive QI strategy to test, measure, and implement changes; and 3) regular communication and collaboration among ED staff, mental healthcare staff, patients/families, and hospital leadership. There were also lessons learned regarding what could have further enhanced project success: 1) enhanced communication strategies using multiple methods to ensure that project communications reached all stakeholders, including those not regularly present in the ED; 2) hiring the QI lead earlier to begin change management prior to bundle implementation; and 3) outlining a transition plan for clinical data management and bundle monitoring earlier to ease the QI transition to clinical leadership.

Utilization of Pediatric Standing Orders by Triage Nurses in a Free-Standing Emergency Department.

Pediatric pain-related complaints continue to be a common presenting factor of most emergency departments (EDs). Studies have shown that several barriers in assessing and treating pediatric pain exist, including nursing knowledge regarding appropriate pain level assessment. This quality improvement study aimed to provide and evaluate specific education regarding pediatric pain management for free-standing ED triage nurses to expedite medication administration during the triage phase of an ED visit. This pre/post-test intervention study was used to measure whether the education provided to nurses working in a primarily adult patient free-standing ED increased the utilization of triage standing orders related to pediatric pain management. Paired sample t-tests results indicated a statistically significant increase (p = .000) in the percentage of patients that received pain medication during the triage phase of an ED visit after specific education was provided to triage nurses. Free-standing ED triage nurses are more likely to follow and implement triage standing orders if education explicitly related to pain management in pediatric patients has been provided. Pediatric pain management education should be revisited annually to re-educate nurses on the importance of early interventions.

A quick Sequential Organ Failure Assessment-negative result at triage is associated with low compliance with sepsis bundles: a retrospective analysis of a multicenter prospective registry.

ObjectiveWe investigated the effects of a quick Sequential Organ Failure Assessment (qSOFA)–negative result (qSOFA score <2 points) at triage on the compliance with sepsis bundles among patients with sepsis who presented to the emergency department (ED).MethodsProspective sepsis registry data from 11 urban tertiary hospital EDs between October 2015 and April 2018 were retrospectively reviewed. Patients who met the Third International Consensus Definitions for Sepsis and Septic Shock criteria were included. Primary exposure was defined as a qSOFA score ≥2 points at ED triage. The primary outcome was defined as 3-hour bundle compliance, including lactate measurement, blood culture, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration. Multivariate logistic regression analysis to predict 3-hour bundle compliance was performed.ResultsAmong the 2,250 patients enrolled in the registry, 2,087 fulfilled the sepsis criteria. Only 31.4% (656/2,087) of the sepsis patients had qSOFA scores ≥2 points at triage. Patients with qSOFA scores <2 points had lower lactate levels, lower SOFA scores, and a lower 28-day mortality rate. Rates of compliance with lactate measurement (adjusted odds ratio [aOR], 0.47; 95% confidence interval [CI], 0.29–0.75), antibiotics administration (aOR, 0.64; 95% CI, 0.52–0.78), and 30 mL/kg crystalloid administration (aOR, 0.62; 95% CI, 0.49–0.77) within 3 hours from triage were significantly lower in patients with qSOFA scores <2 points. However, the rate of compliance with blood culture within 3 hours from triage (aOR, 1.66; 95% CI, 1.33–2.08) was higher in patients with qSOFA scores <2 points.ConclusionA qSOFA-negative result at ED triage is associated with low compliance with lactate measurement, broad-spectrum antibiotics administration, and 30 mL/kg crystalloid administration within 3 hours in sepsis patients.

Emergency department triage and COVID‐19: Performance of the Interagency Integrated Triage Tool during a pandemic surge in Papua New Guinea

ObjectiveTo determine the sensitivity of the Interagency Integrated Triage Tool to identify severe and critical illness among adult patients with COVID‐19.MethodsA retrospective observational study conducted at Port Moresby General Hospital ED during a three‐month Delta surge.ResultsAmong 387 eligible patients with COVID‐19, 63 were diagnosed with severe or critical illness. Forty‐seven were allocated a high acuity triage category, equating to a sensitivity of 74.6% (95% CI 62.1–84.7) and a negative predictive value of 92.7% (95% CI 88.4–95.8).ConclusionIn a resource‐constrained context, the tool demonstrated reasonable sensitivity to detect severe and critical COVID‐19, comparable with its reported performance for other urgent conditions.

Improving the accuracy of Nurse Initiated X-ray Orders (NIXO) in the Emergency Department

Purpose: In Sengkang General Hospital (SKH), Emergency Department (ED) triage nurses are privileged to order x-rays for patients prior to consultation with the ED doctors based on the initial presenting complaints. This workflow was implemented to improve the efficiency of patient management in ED. However, SKH ED radiographers encountered several orders from triage nurses that were deemed inappropriate or inaccurate. Such orders have led to several near-miss cases that could compromise patient safety and potential medico-legal issues. It also subjects patients to unnecessary radiation. This study aims to evaluate if using an educational tool can improve the accuracy of x-ray orders by ED triage nurses.Methods: Inappropriate or inaccurate x-ray orders are defined as x-ray orders that are ordered for incorrect region, incorrect side or inaccurate clinical history. An educational package in the form of presentation slides was created for the nurses by a team of radiographers. This package is called NIXO, an abbreviation of Nurse Initiated X-ray Orders. NIXO was then presented to the ED triage nurses during their monthly Continuing Professional Development (CPD) session in June 2021. With the assistance of the ED nursing education team, data for nurse's x-ray orders were obtained three months before and after the CPD session. The results of this data will determine the effectiveness of the NIXO presentation to the triage nurses.Results: Data was collected between April 2021 to June 2021 (pre-CPD) and August 2021 to October 2021 (post-CPD). It was found in the initial results that there is a drop in the x-ray orders error rates. This showed that there has been an improvement in the accuracy of ED triage nurse's x-ray ordering. In addition, in a post-CPD presentation survey conducted, 99% of the triage nurses found this initiative to be helpful in their clinical work. Collection of data is still ongoing up till February 2022. The results of this study will be evaluated once again in February 2022.Conclusion: Based on the preliminary findings of this study, it suggests that NIXO has helped reduce the number of inappropriate orders made by ED triage nurses. This inter-professional education initiative has provided ED triage nurses with the knowledge required to order X-rays competently whilst ensuring patient safety and providing care. As such, NIXO education package will be integrated into the ED triage course in future. Purpose: In Sengkang General Hospital (SKH), Emergency Department (ED) triage nurses are privileged to order x-rays for patients prior to consultation with the ED doctors based on the initial presenting complaints. This workflow was implemented to improve the efficiency of patient management in ED. However, SKH ED radiographers encountered several orders from triage nurses that were deemed inappropriate or inaccurate. Such orders have led to several near-miss cases that could compromise patient safety and potential medico-legal issues. It also subjects patients to unnecessary radiation. This study aims to evaluate if using an educational tool can improve the accuracy of x-ray orders by ED triage nurses. Methods: Inappropriate or inaccurate x-ray orders are defined as x-ray orders that are ordered for incorrect region, incorrect side or inaccurate clinical history. An educational package in the form of presentation slides was created for the nurses by a team of radiographers. This package is called NIXO, an abbreviation of Nurse Initiated X-ray Orders. NIXO was then presented to the ED triage nurses during their monthly Continuing Professional Development (CPD) session in June 2021. With the assistance of the ED nursing education team, data for nurse's x-ray orders were obtained three months before and after the CPD session. The results of this data will determine the effectiveness of the NIXO presentation to the triage nurses. Results: Data was collected between April 2021 to June 2021 (pre-CPD) and August 2021 to October 2021 (post-CPD). It was found in the initial results that there is a drop in the x-ray orders error rates. This showed that there has been an improvement in the accuracy of ED triage nurse's x-ray ordering. In addition, in a post-CPD presentation survey conducted, 99% of the triage nurses found this initiative to be helpful in their clinical work. Collection of data is still ongoing up till February 2022. The results of this study will be evaluated once again in February 2022. Conclusion: Based on the preliminary findings of this study, it suggests that NIXO has helped reduce the number of inappropriate orders made by ED triage nurses. This inter-professional education initiative has provided ED triage nurses with the knowledge required to order X-rays competently whilst ensuring patient safety and providing care. As such, NIXO education package will be integrated into the ED triage course in future.

Machine learning-based suggestion for critical interventions in the management of potentially severe conditioned patients in emergency department triage

Providing timely intervention to critically ill patients is a challenging task in emergency departments (ED). Our study aimed to predict early critical interventions (CrIs), which can be used as clinical recommendations. This retrospective observational study was conducted in the ED of a tertiary hospital located in a Korean metropolitan city. Patient who visited ED from January 1, 2016, to December 31, 2018, were included. Need of six CrIs were selected as prediction outcomes, namely, arterial line (A-line) insertion, oxygen therapy, high-flow nasal cannula (HFNC), intubation, Massive Transfusion Protocol (MTP), and inotropes and vasopressor. Extreme gradient boosting (XGBoost) prediction model was built by using only data available at the initial stage of ED. Overall, 137,883 patients were included in the study. The areas under the receiver operating characteristic curve for the prediction of A-line insertion was 0·913, oxygen therapy was 0.909, HFNC was 0.962, intubation was 0.945, MTP was 0.920, and inotropes or vasopressor administration was 0.899 in the XGBoost method. In addition, an increase in the need for CrIs was associated with worse ED outcomes. The CrIs model was integrated into the study site's electronic medical record and could be used to suggest early interventions for emergency physicians.

Clinical Outcomes Following Implementation of a Formalized “Flashes and Floaters” Emergency Department Triage Protocol

To report outcomes of patients presenting to the emergency department (ED) with new-onset visual flashes and/or floaters following implementation of a formalized triage protocol allowing eligible patients to be discharged for prompt outpatient ophthalmic examination. Retrospective consecutive case series. Patient characteristics, protocol eligibility, and clinical outcomes were recorded for adult patients triaged within a formal "flashes and floaters" protocol at a single academic ED. A total of 457 patients presented for 471 unique ED encounters with a chief complaint of visual flashes and/or floaters between October 2014 and May 2018. In all, 61% of patient encounters (287/471) met protocol criteria for prompt outpatient ophthalmic examination, of whom 94% (269/287) were examined within 48 hours. Final diagnoses of protocol-eligible patients were posterior vitreous detachment only (73%, 197/269), retinal break(s)(10%, 26/269), migraine (5%, 14/269), and no cause or new cause found (10%, 27/269). No protocol-eligible patients had retinal detachment or diagnoses requiring emergent diagnostic or therapeutic care (0%, 95% CI=0%-1.1%). Final diagnoses following 175 encounters not meeting criteria for deferred examination included posterior vitreous detachment only (25%, 43/175), retinal break(s) (19%, 33/175), macula-involving retinal detachment (13%, 22/175), macula-sparing retinal detachment (11%, 19/175), retinal arterial occlusion (2%, 3/175), and stroke (0.6%, 1/175). The Cohen kappa for agreement on protocol eligibility between the ED physician and ophthalmologist was 0.85. A formalized ED "flashes and floaters" triage protocol may help identify patients for whom prompt outpatient ophthalmic examination may be more safely considered.

Assessment of the Stability of Midregional Proadrenomedullin in Different Biological Matrices.

Midregional proadrenomedullin (MR-proADM) has been shown to play a key role in endothelial dysfunction, with increased levels helping to prevent early stages of organ dysfunction. Recent clinical evidence has demonstrated MR-proADM to be a helpful biomarker to identify disease severity in patients with sepsis as well as pneumonia. This biomarker is helpful at triage in emergency departments to assess risk level of patients. The aim of this study is to evaluate the stability of MR-proADM in different biological matrices. The results, obtained by Bland-Altman and scatter plot analyses, demonstrate that deviation of MR-proADM concentration in serum compared to EDTA plasma unequivocally shows that serum should not be used as a sample matrix. Instead, the excellent correlation of heparin plasma vs EDTA plasma samples shows that heparin plasma can be used without reservation in clinical routine and emergency samples.

Investigation of the usability of the REMS, RAPS, and MPM II0 scoring systems in the prediction of short-term and long-term mortality in patients presenting to the emergency department triage.

Appropriate triage is an important component of patient management in emergency departments. The risk scoring system used for triage purposes in emergency departments should be obtained quickly and based on parameters directly related to prognosis. To investigate the success of the Rapid Emergency Medicine Score (REMS) and Rapid Acute Physiology Score (RAPS) as triage scoring systems and the Mortality Probability Model (MPM II0) as an intensive care scoring system in identifying critical patients visited to the emergency department (ED) triage and predicting mortality, and to evaluate their superiority over each other, if any. This research was planned as a single-center and prospectively. The data of the study were obtained by screening the medical records of all patients who presented to the ED triage between January 1, 2020 and January 31, 2020. Patients under the age of 18years, those with missing information in their files and pregnant women were not included in the study. Only the patients for whom the REMS, RAPS, and MPM II0 scores could be calculated were included in the sample. After excluding the patients who did not meet the inclusion criteria, the study was completed with 12,210 patients. The mean age of these patients was 44.7 ± 18.7years, and 47.3% were male. The area under the receiver operating characteristics curve values for the prediction of 24-h, 30-day, 90-day, and 180-day mortality were determined as 0.979, 0.921, 0.904, and 0.897, respectively, for REMS; 0.929, 0.778, 0.75, and 0.725, respectively, for RAPS; and 0.925, 0.888, 0.866, and 0.861, respectively, for MPM II0. In this study, it was concluded that the REMS score was superior to the MPM II0 and RAPS scores in predicting the short-term and long-term mortality status of patients and determining the discharge and hospitalization status of the patients.