Triage Level Research Articles

National Early Warning Score 2 (NEWS2) and 3-level triage scale as risk predictors in frail older adults in the emergency department

BackgroundThe aim of the emergency department (ED) triage is to recognize critically ill patients and to allocate resources. No strong evidence for accuracy of the current triage instruments, especially for the older adults, exists. We evaluated the National Early Warning Score 2 (NEWS2) and a 3-level triage assessment as risk predictors for frail older adults visiting the ED.MethodsThis prospective, observational study was performed in a Finnish ED. The data were collected in a six-month period and included were ≥ 75-year-old residents with Clinical Frailty Scale score of at least four. We analyzed the predictive values of NEWS2 and the three-level triage scale for 30-day mortality, hospital admission, high dependency unit (HDU) and intensive care unit (ICU) admissions, a count of 72-h and 30-day revisits, and ED length-of-stay (LOS).ResultsA total of 1711 ED visits were included. Median for age, CFS, LOS and NEWS2 were 85 years, 6 points, 6.2 h and 1 point, respectively. 30-day mortality was 96/1711. At triage, 69, 356 and 1278 of patients were assessed as red, yellow and green, respectively. There were 1103 admissions, of them 31 to an HDU facility, none to ICU.With NEWS2 and triage score, AUCs for 30-day mortality prediction were 0.70 (0.64–0.76) and 0.62 (0.56–0.68); for hospital admission prediction 0.62 (0.60–0.65) and 0.55 (0.52–0.56), and for HDU admission 0.72 (0.61–0.83) and 0.80 (0.70–0.90), respectively.The NEWS2 divided into risk groups of low, medium and high did not predict the ED LOS (p = 0.095). There was a difference in ED LOS between the red/yellow and as red/green patient groups (p < 0.001) but not between the yellow/green groups (p = 0.59).There were 48 and 351 revisits within 72 h and 30 days, respectively. With NEWS2 AUCs for 72-h and 30-day revisit prediction were 0.48 (95% CI 0.40–0.56) and 0.47 (0.44–0.51), respectively; with triage score 0.48 (0.40–0.56) and 0.49 (0.46–0.52), respectively.ConclusionsThe NEWS2 and a local 3-level triage scale are statistically significant, but poor in accuracy, in predicting 30-day mortality, and HDU admission but not ED LOS or revisit rates for frail older adults. NEWS2 also seems to predict hospital admission.

Impact of the COVID-19 Pandemic on Emergency Department Use: Focus on Patients Requiring Urgent Revascularization.

BackgroundThe novel coronavirus (2019-nCOV) appeared in China and precipitously extended across the globe. As always, natural disasters or infectious disease outbreaks have the potential to cause emergency department (ED) volume changes.ObjectiveWe aimed to assess the influence of the Coronavirus Disease 2019 (COVID-19) pandemic on ED visits and the impact on the handling of patients requiring urgent revascularization.MethodsWe reviewed the charts of all patients presenting to the ED of Hospital Sainte Anne (Toulon, France) from March 23 to April 5, 2020 and compared them with those of the same period in 2019. Then we analyzed complementary data on acute coronary syndrome (ST-elevation myocardial infarction [STEMI] and non-ST-elevation myocardial infarction [NSTEMI]) and neurovascular emergencies (strokes and transient ischemic attacks).ResultsThe total number of visits decreased by 47%. The number of people assessed as triage level 2 was 8% lower in 2020. There were five fewer cases of NSTEMI in 2020, but the same number of STEMI. The number of neurovascular emergencies increased (27 cases in 2019 compared with 30 in 2020). We observed a reduction in the delay between arrival at the ED and the beginning of coronary angiography for STEMI cases (27 min in 2019 and 22 min in 2020). In 2020, 7 more stroke patients were admitted.ConclusionThe COVID-19 pandemic probably dissuaded “non-critical” patients from coming to the hospital, whereas the same number of patients with a critical illness attended the ED as attended prior to the pandemic. There does not seem to have been any effect of the pandemic on patients requiring reperfusion therapy (STEMI and stroke).

Emotional adaptation to relationship dissolution in parents and non-parents: A new conceptual model and measure.

Relationship dissolution can cause declines in emotional well-being, particularly if there are children involved. Individuals’ capacity to cope with the pragmatics of the situation, such as agreeing childcare arrangements, can be impaired. Before now, there has been no psychometric test to evaluate individuals’ emotional readiness to cope with these demands. This paper presents a model of emotional adaptation in the context of relationship dissolution and its key assumptions, and validates the Emotional Adaptation to Relationship Dissolution Assessment (EARDA). In Study 1 (Sample 1, n = 573 separated parents, Sample 2, n = 199 mix of parents and non-parents), factor analyses support the EARDA as a unidimensional scale with good reliability. In Study 2 (using Sample 1, and Sample 3, n = 156 separated parents) the convergent, discriminant, concurrent criterion-related, and incremental validity of the EARDA were supported by tests of association with stress, distress, attachment style, and co-parenting communication and conflict. In Study 3, the nomological network of emotional adaptation to relationship dissolution was explored in Sample 2 using cluster analysis and multi-dimensional scaling (MDS). Emotional adaptation clustered with positive traits and an outward focus, and was negatively associated with negative traits and an inward focus. Emotional adaptation was conceptually located in close proximity to active and adaptive coping, and furthest away from maladaptive coping. In Study 4 (n = 30 separated parents embarking on mediation), high, medium, and low emotional adaptation to relationship dissolution categories correlated highly with mediators’ professional judgement, offering triangulated face validity. Finally, in Study 5, EARDA scores were found to mediate between separation characteristics (time since break up, whether it was a shock, and who initiated the break up) and co-parenting conflict in Sample 1, supporting the proposed model. The theoretical innovation of this work is the introduction of a new construct that bridges the gap between relationship dissolution and co-parenting. Practical implications include the use of the measure proposed to triage levels of support in a family law setting.

Evaluation of the Relationship Between Socio-Economic Level and Severity of Emergency

Background; Social Class has shown relation with admissions at Emergency Departments. To assess whether there is a relationship between the level of triage and the social class of patients who attend the emergency department and whether there are other variables that can modulate this association. Methods Observational study with 1000 patients was carried out between May and July 2018 in the Emergency Department of the University Hospital Arnau de Vilanova in Lleida. Sociodemographic variables such as age, gender, country of origin and marital status were analyzed. The triage level and the main explanatory variable was social class. Social class was calculated based on the CSO-SEE 2012 scale. Results 49.4% were male and the average age was 51.7 years. Most of the patients (66.6%) attended the emergency department under their own volition and the most common triage levels were level III or Emergency (45%). There is a significant relationship between age and triage level. The younger patients had a lower triage level (p &lt;0.001). The percentage of patients with lower social class who attended the emergency department for minor reasons was 42% higher compared to the rest of the patients (RR = 1.42; 1.21-1.67 95% CI, p &lt;0.001). Conclusions; Patients with a lower socioeconomic class go to the Emergency Department for less serious pathologies.

Preventive Measures for COVID-19 in Dental Treatments.

The 2019 coronavirus disease (COVID-19) has spread to most countries around the world, infecting millions of people and resulting in the pandemic. This presents great challenges for dental professionals. It is necessary to explore preventive measures for COVID-19 in dental treatments. In this paper, we outline several measures designed to prevent COVID-19 in dental treatments, such as 3-level pre-examination triage and 2-body temperature tests, 3-level protection for medical personnel, gargling before oral treatment, implementing the 4-hand operation, suctioning saliva during oral treatment, using a rubber dam, and strict enforcement of hand hygiene. These measures include recommendations for medical staff and give practical advice for managing treatment. The epidemic has been brought under control, and routine oral examination and treatments have gradually been resumed from March 9, 2020, in Hunan Province, China. From January 24 to March 8, 2020, a total of 4272 patients received oral therapy during the COVID-19 epidemic in our hospital. We followed these guidelines during the COVID-19 epidemic, and none of the clinical dental staff, other workers, or patients were infected with COVID-19. These preventive measures for COVID-19 in dental treatments can be used as a reference for oral clinics and stomatological hospitals.

Estudio sobre el subtriaje del Sistema de Triaje de Manchester en pacientes que acuden a Urgencias por cefalea

IntroductionHeadache is a frequent cause of consultation; it is important to detect patients with secondary headache, particularly high-risk secondary headache. Such systems as the Manchester Triage System (MTS) are used for this purpose. This study aims to evaluate the frequency of sub-triage in patients attending the Emergency Department due to headache. Material and methodsWe studied a series of consecutive patients who came to the Emergency Department with headache and presenting some warning sign, defined as the presence of signs leading the physician to request an emergency neuroimaging study and/or assessment by the on-call neurologist. The reference diagnosis was established by neurologists. We evaluated the MTS triage level assigned and the presence of warning signs that may imply a higher level than that assigned. ResultsWe registered a total of 1,120 emergency department visits due to headache, and 248 patients (22.8%) were eligible for study inclusion. Secondary headache was diagnosed in 126 cases (50.8% of the sample; 11.2% of the total), with 60 cases presenting high-risk secondary headache (24.2%; 5.4%). According to the MTS, two patients were classified as immediate (0.8%), 26 as very urgent (10.5%), 147 as urgent (59.3%), 68 as normal (27.4%), and five as not urgent (2%). The percentage of patients under-triaged was 85.1% in the very urgent classification level and 23.3% in the urgent level. ConclusionDuring the study period, at least one in 10 patients attending the Emergency Department due to headache had secondary headache; one in 20 had high-risk secondary headache. The MTS under-triaged most patients with warning signs suggesting a potential emergency.

Reducing waiting time for remote patients in telemedicine with considering treated patients in emergency department based on body sensors technologies and hybrid computational algorithms: Toward scalable and efficient real time healthcare monitoring system.

Scalability challenge in real time healthcare monitoring system relates to several issues. One of the insistent issues is the increasing in the number of patients. Increasing in the patients' number causes long queue and increase the waiting time for the patients in their seeking for healthcare services. Thus, an ethical issue raises as the healthcare providers should provide fast services for all patients. Recent studies have proposed scalable models that are limited to (1) triaging remote patients for the optimal emergency level and (2) prioritizing remote patients with the highest triage level to receive immediate healthcare services. However, these studies have shown limitations, that is, (1) they have not addressed the waiting time for all patients with different triage levels in the same waiting queue; and (2) they have not considered Emergency Department EDs patients. Therefore, considering the remote patients with the treated patients in EDs in one healthcare system is a demand, to efficiently handle all the patients' requests and productively manage the medical resources. This study aims to reduce the waiting time for the remote patients in telemedicine with considering treated patients in EDs. The study presents a scalable telemedicine model to improve the ability of real time healthcare monitoring system in accommodating the increasing number of patients with chronic heart disease by reducing their waiting time for healthcare services, prioritizing the patients who have the most emergency cases and provide all the patients by fast healthcare services. The proposed model called Triaging and Prioritizing Model "TPM". The proposed model "TPM" considers triaging and prioritizing all patients (remote and EDs patients) as two sequential processes. The TPM was formulated to triage the patients based on hybrid algorithms which combine Evidence-Theory with Fuzzy Cluster Means (FCM) and then prioritize the patients based on dedicated computational algorithm. A simulation, on 580 chronic heart diseases patients, was implemented. The patients considered as they have different emergency levels based on four vital data acquisition tools: electrocardiogram sensor, blood pressure sensor, oxygen saturation sensor and a text input as non-sensory based acquisition tool. Computational results show the superiority of the proposed model (TPM) in accommodating large numbers of patients and reducing their waiting time for services compared with relevant benchmark studies. In 1,185min, TPM managed the (580) patients' requests. By contrast, the benchmark managed only 256 patients at the same amount of time. In addition to that, TPM shows improvements in terms of waiting time and services provisioning rates compared with benchmark methods. All patients with the different emergency levels receive services with less waiting time compared with the relevant studies. The proposed model (TPM) model considers both of remote patients and treated patients in EDs efficiently. TPM improves response time for the medical services, reduces waiting time for all patients and consequently, saves more lives.

Paediatric emergency department visits for non-urgent conditions: Can family medicine prevent this?

Background In Turkey, family physicians serve only during office hours, while emergency services have 7/24 free access. Non-urgent patients commonly use Paediatric Emergency departments (PEDs). In Turkey, there is little evidence as to why emergency services are used instead of family medicine for non-urgent paediatric healthcare. Objectives To evaluate the causes and factors affecting non-urgent PED visits. To determine the reason for non-use of family medicine for non-urgent paediatric healthcare. Methods We conducted a cross-sectional study at Gaziantep University PED between April and May 2019. We administered a questionnaire to the parents of children (from one month to 16 years) triaged to non-urgent (level-5) using a 5-level triage system. Results A total of 457 parents were surveyed. The average patient age was 6.5 ± 4.7 years and 24.5% had a chronic disease. One-third of the parents (33.7%) considered their children’s condition ‘very urgent’. The most important reason for preferring PED (42.5%) instead of family physician or alternative health facilities was the thought that the condition of children would worsen. Two hundred fifty-three (55.4%) of the patients presented outside working hours. Although 58.9% of parents were satisfied with the family physician, most (67.8%) stated that they preferred other specialists rather than family physicians when the child had health problems. Fathers who were primary school graduates were more likely to prefer other specialists than family physicians. Conclusion Parents’ perception of urgency and the thought that their child’s condition will worsen are the main reasons for non-urgent using PED.

Impact of the COVID-19 pandemic on emergency department: Early findings from a hospital in Madrid

IntroductionSARS-CoV-2, coronavirus that causes coronavirus disease 2019 (COVID-19), was first detected in Spain on 31 January 2020. On 14 March 2020, a state of emergency was declared in Spain in a bid to control the spread of the COVID-19 pandemic in the country. The aim of our study is to analyze the impact on emergency medicine attendance after the national lockdown, as well as the clinical presentation and the management of patients with suspected COVID-19 in the Paediatric Emergency Department. Patients and methodsThis retrospective observational study included children and adolescents under the age of 18, attended in our Paediatric Emergency Department during the period March 14 to April 17, 2020. ResultsA total of 1666 patients were attended during the study period, 65.4% less than in the same period of 2019. Just over half (51.2%) were males, and mean age was 5.4 years. In triage, 39.9% were high priority levels, 6.5% more than 2019. Most frequent reasons for consultation at the Paediatric Emergency Department were fever (26.5%), respiratory symptoms (16.1%), and trauma (15.2%). A total of 218 patients (13%) received a diagnosis of possible COVID-19, with SARS-CoV-2 infection confirmed in 18.4%, and 23.8% (52/218) were hospitalised. At discharge, 44% (96/218) were diagnosed with lower, and 33.9% (74/218) with upper respiratory infection. ConclusionsDuring the SARS-CoV-2 outbreak, the demand for urgent paediatric care decreased, with the proportion of cases with high priority triage levels increasing. Most of the patients with suspected or microbiological confirmation of COVID-19 had mild respiratory symptoms.

Evaluation of Patient Flow and Waiting Time for the First Physician Visit in an Overcrowded Emergency Department

Background: The velocity of providing services in health centers is crucial to reduce mortality and adverse outcomes. Objectives: The present study aimed at determining the waiting time from entering the emergency department (ED) up to physician visiting based on congestion in the triple shift at Shahid Mohammadi Hospital in Bandar Abbas, Iran. Methods: The current cross-sectional, analytical study was conducted in 2019 on 1285 subjects selected from three shifts. The data collection tools included demographic data and standard triage forms, as well as a timetable with a stopwatch. The time between patient arrival and physician visit was recorded. SPSS software version 21 was employed to analyze the data. Results: The highest percentage of patients, 65.1% (n = 837), was non-traumatic, 38.98% (n = 501) referred during the evening shift, and 47.54% (n = 611) were related to the triage level 3. The maximum average waiting time from the beginning to the end of the triage was 4.46, and up to the physician, the visit was 12.8 minutes. Waiting time from entering ED up to physician first visit in terms of gender, refer to ED, and cause of referral statistically divulged a significant difference (P &lt; 0.05). Estimation of the maximum congestion in the department was from 16:00 to 20:00, which showed a significant difference with other day times (P &lt; 0.05). Conclusions: The average waiting time for patients was higher than the global standard. The interventions based on the maximum congestion in ED can be effective in reducing patient waiting time.

Clinical factors associated with the use of dexamethasone for asthma in the pediatric emergency department

Background Dexamethasone is efficacious for the treatment of pediatric asthma exacerbations but is not specifically recommended by current national guidelines. Objectives To describe the factors associated with prescribed dexamethasone in a pediatric emergency department (PED) and upon patient discharge. Methods Retrospective chart review of patients aged 2 to 18 years discharged home from a PED with a diagnostic code for asthma (J45x). Descriptive statistics are reported and binary logistic regression with generalized estimating equations was used to examine the demographic and clinical factors associated with dexamethasone use in the PED and upon discharge. Results 594 children contributed 690 visits for asthma. Two-thirds of patients received prednisone in the PED (n = 430; 62%). Among 260 children who received dexamethasone, 76% (n = 198) were prescribed a second dose for post-discharge administration. Multivariable models showed that patients triaged as most urgent had a 50% reduction in the odds of receiving dexamethasone in the PED (OR = 0.5; 95% CI = 0.28–0.87). Patients seen by a pediatrician (OR 4.2; 95%CI 2.1–8.3) and those triaged as urgent (OR 2.9; 95% CI = 1.8–7.8) were more likely to receive a single dose of dexamethasone. Conclusions Dexamethasone is less commonly used in the PED for asthmatic patients triaged as most urgent. Triage acuity and level of training were associated with single-dose treatment of asthma in those receiving dexamethasone. Further studies are needed to clarify the use of dexamethasone across the spectrum of asthma severity.

Evaluation of the risk factors associated with emergency department boarding: A retrospective cross-sectional study

PurposeBoarding is a common problem in the emergency department (ED) and is associated with poor health care and outcome. Imam Khomeini Hospital is the main healthcare center in Urmia, a metropolis in the northwest of Iran. Due to the overcrowding and high patient load, we aim to characterize the rate, cause and consequence of boarding in the ED of this center. MethodsAll medical records of patients who presented to the ED of Imam Khomeini Hospital from August 1, 2017 to August 1, 2018 were retrospectively analyzed. Patients with uncompleted records were excluded. Boarding was defined as the inability to transfer the admitted ED patients to a downstream ward in ≥2 h after the admission order. Demographic data, boarding rate, mortality and triage levels (1–5) assessed by emergency severity index were collected and analyzed. The first present time of patients was classified into 4 ranges as 0:00–5:59, 6:00–11:59, 12:00–17:59 and 18:00–23:59. Descriptive, parametric and non-parametric statistical tests were performed and the risk of boarding was determined by Pearson Chi-square test. ResultsDemographic data analysis showed that 941 (58.5%) male and 667 (41.5%) female, altogether 1608 patients were included in this study. Five patients (0.3%) died. The distribution of patients with the triage levels 1–5 was respectively 79 (4.9%), 1150 (71.5%), 374 (23.3%), 4 (0.2%) and 0 (0%). Most patients were of level 2. Only 75 (4.7%) patients required intensive care. The majority of patients (84.2%) were presented at weekdays. The maximum patient load was observed between 12:00–17:59. Of the 1608 patients, 340 (21.1%) experienced boarding within a mean admission time of 13.70 h. Among the 340-boarded patients, 20.1% belonged to surgery, 12.1% to orthopedics, 10.9% to neurosurgery and 10.3% to neurology. The boarding rate was higher in females, patients requiring intensive care and those with low triage levels. Compared with the non-boarded, the boarded patients had a higher mean age. ConclusionThe boarding rate is higher in the older and female patients. Moreover, boarding is dependent on the downstream ward sections: patients requiring surgical management experience the maximum boarding rate.

The impact of the coordinating nurse role on patient satisfaction in the emergency department: a semi-experimental study

Objective: This study was conducted to investigate the role of an emergency nurse coordinator (ENC) in improving patient satisfaction at the emergency department (ED) in Tehran, Iran.Methods: This was an interventional study in the field of ED management. This study was undertaken in the ED of Sina hospital in Tehran, Iran, during March 2018 until April 2019. An ENC was assigned to the ED on even days and during the next week. Also, the presence of the ENC was switched to odd days and so on. Patient satisfaction was evaluated by a questionnaire. In order to analyze data, independent T-test was used to assess the mean difference in satisfaction scores. In addition, analysis of covariance (ANCOVA) test was utilized to assess the difference in satisfaction scores after considering age, sex and triage level as confounding variables. Results: Finally, 315 and 291 patients were allocated to the intervention (patients with ENC) and control groups (patients without ENC), respectively. The total satisfaction rate in the intervention and control groups was 63.9% and 59.3%, respectively. The mean score of total satisfaction in the intervention group was significantly higher than the control group [115.1 (SD = 20.0) vs 106.8 (SD = 22.3); P < 0.001]. The ANCOVA analysis showed that age, sex and triage level were not confounding factors affecting the satisfaction score.Conclusion: This study showed that the presence of the ENC in the ED can increase patient satisfaction, especially in domains related to “diagnostic and therapeutic services”, “cleanliness”, “cost and discharge information”, “ethical and privacy issues”, “admission, discharge and management services”.

Forecasting emergency admissions in the city of Milan to predict overflow: a 2-day warning system

BackgroundThe emergency department (ED) is one of the most critical area in any hospitals. In Italy, the mean waiting time is increasing causing potentially ED overflow and a detrimental effect on quality of care.MethodsWe collected total daily ED visits between 2014 and 2019 in the five major hospitals of Milan. To predict daily volumes, we used a regression model with ARIMA errors. Predictors included were weekly and yearly periodicity, meteorological and environmental variables, information on influenza epidemics and festivities. Parameters have been calibrated on training datasets (2014-2018) and successively validated on 2019, accuracy of prediction have been evaluated with the Mean Absolute Percentage Error (MAPE). Finally, we evaluated the impact of the COVID-19 outbreak calculating the proportion of ED accesses by triage levels, before and after the outbreak.ResultsBetween 2014 and 2019 there have been 2 million of ED visits in the hospitals of Milan. We found different patterns of ED visits across age and days: children (0-14 years) tended to visit ED more likely on weekends while adults and senior people on Mondays. Results confirmed the role of meteorological and environmental variables, and the presence of yearly and weekly pattern. We found high correlation between observed and predicted value with a MAPE globally smaller than 8.1%. During the COVID-19 outbreak, the number of white triage ED accesses was reduced up to 71%.ConclusionsResults permitted to develop a 2-day ED warning system combining forecast data provided by ARPA Lombardia. This is crucial in a system where inappropriate emergency admissions are still high where the analysis conducted during the COVID-19 pandemic period suggested a dramatic reduction in the number of daily ED access of lower triages.Key messages The ability to forecast future demands would be a valuable support in a system of limited resources, which must therefore be used in the best way.Environmental and meteorological variable have a moderate effect on emergency admissions.

Evaluation of the Emergency Severity Index (Version 4) in Postpartum Women after Cesarean Delivery.

The Emergency Severity Index (ESI) version 4 is a 5-level triage system (1 being the highest acuity and 5 being the lowest acuity) used in the emergency department (ED). Our goal of the study was to compare rates of readmission according to ESI in postpartum women. This was a secondary analysis of a retrospective cohort study of all women who presented to the ED within 6 weeks after cesarean delivery. The acuity level was assigned by triage nurses at the time of triage presentation. Our primary outcome was postpartum readmission. To examine if the addition of blood pressure to vital sign abnormalities would improve the prediction for readmission, we created a modified ESI. We identified women who had an ESI of level 3 and reassigned to a modified ESI of level 2 if blood pressure was in the severe range. Receiver operating characteristic curves with area under the curve (AUC) were created and compared between ESI and modified ESI. Of 439 women, ESI distribution was 0.2% ESI 1, 23.7% ESI 2, 56.0% ESI 3, 19.4% ESI 4, and 0.7% ESI 5. Readmission rates by ESI level were 100% ESI 1, 47% ESI 2, 18% ESI 3, 2% ESI 4, and 0% ESI 5 (p < 0.001). Of 246 women who were assigned an ESI of 3, total 25 had severe range blood pressures and were reassigned to a modified ESI of 2. Of these 25 women, 14 were readmitted. The AUC of the modified ESI was statistically higher than that of the standard ESI (AUC: 0.77 and 95% confidence interval: 0.72-0.82 vs. AUC: 0.73 and 95% confidence interval: 0.68-0.78; p < 0.01). The ESI was a useful tool to identify women who required postpartum readmission. Incorporation of severe range blood pressure as a parameter of acuity improved the prediction of readmission. · ESI does not consider blood pressure.. · The ESI version 4 was predictive of postpartum readmission.. · Consideration of a severe range blood pressure significantly improved the prediction of readmission..

Dispatcher Triage Accuracy in the Western Cape Government Emergency Medical Services System, Cape Town, South Africa.

Triage - the sorting of patients according to urgency of need for clinical care - is an essential part of delivering effective and efficient emergency care. But when frequent over- or under-triaging occurs, finite time and resources are diverted away from those in greatest need of care and the entire Emergency Medical Services (EMS) system is strained. In resource-constrained settings, such as South Africa, poor triage in EMS only serves to compound other contextual challenges. This study examined the accuracy of dispatcher triage over a one-year period in the Western Cape Government (WCG) EMS system in South Africa. A retrospective analysis of existing dispatch and EMS data to assess the accuracy of dispatch-assigned priorities was conducted. The mismatch between dispatcher-assigned call priority and triage levels determined by EMS personnel was analyzed via over- and under-triage rates, sensitivity and specificity, and positive and negative predictive values (PPVs and NPVs, respectively). A total of 185,166 records from December 2016 through November 2017 were analyzed. Across all dispatch complaints, the over-triage rate was 67.6% (95% CI, 66.34-68.76) and the under-triage rate was 16.2% (95% CI, 15.44-16.90). Dispatch triage sensitivity for all included records was 49.2% (95% CI, 48.10-50.38), specificity 71.9% (95% CI, 71.00-72.92), PPV 32.5% (95% CI, 30.02-34.88), and NPV 83.8% (95% CI, 81.93-85.73). This study provides the first evaluation of dispatch triage accuracy in the WCG EMS system, identifying that the system is suffering from both under- and over-triage. Despite variance across dispatch complaints, both under- and over-triage remained higher than widely accepted norms, and all rates were significantly above acceptable target metrics described in similar studies. Results of this study will be used to motivate the development of more rigorous training programs and resources for WCG EMS dispatchers, including improved dispatch protocols for conditions suffering from high over- and under-triage.

Variation in antibiotic prescription rates in febrile children presenting to emergency departments across Europe (MOFICHE): Amulticentreobservational study.

The prescription rate of antibiotics is high for febrile children visiting the emergency department (ED), contributing to antimicrobial resistance. Large studies at European EDs covering diversity in antibiotic and broad-spectrum prescriptions in all febrile children are lacking. A better understanding of variability in antibiotic prescriptions in EDs and its relation with viral or bacterial disease is essential for the development and implementation of interventions to optimise antibiotic use. As part of the PERFORM (Personalised Risk assessment in Febrile illness to Optimise Real-life Management across the European Union) project, the MOFICHE (Management and Outcome of Fever in Children in Europe) study aims to investigate variation and appropriateness of antibiotic prescription in febrile children visiting EDs in Europe. Between January 2017 and April 2018, data were prospectively collected on febrile children aged 0-18 years presenting to 12 EDs in 8 European countries (Austria, Germany, Greece, Latvia, the Netherlands [n = 3], Spain, Slovenia, United Kingdom [n = 3]). These EDs were based in university hospitals (n = 9) or large teaching hospitals (n = 3). Main outcomes were (1) antibiotic prescription rate; (2) the proportion of antibiotics that were broad-spectrum antibiotics; (3) the proportion of antibiotics of appropriate indication (presumed bacterial), inappropriate indication (presumed viral), or inconclusive indication (unknown bacterial/viral or other); (4) the proportion of oral antibiotics of inappropriate duration; and (5) the proportion of antibiotics that were guideline-concordant in uncomplicated urinary and upper and lower respiratory tract infections (RTIs). We determined variation of antibiotic prescription and broad-spectrum prescription by calculating standardised prescription rates using multilevel logistic regression and adjusted for general characteristics (e.g., age, sex, comorbidity, referral), disease severity (e.g., triage level, fever duration, presence of alarming signs), use and result of diagnostics, and focus and cause of infection. In this analysis of 35,650 children (median age 2.8 years, 55% male), overall antibiotic prescription rate was 31.9% (range across EDs: 22.4%-41.6%), and among those prescriptions, the broad-spectrum antibiotic prescription rate was 52.1% (range across EDs: 33.0%-90.3%). After standardisation, differences in antibiotic prescriptions ranged from 0.8 to 1.4, and the ratio between broad-spectrum and narrow-spectrum prescriptions ranged from 0.7 to 1.8 across EDs. Standardised antibiotic prescription rates varied for presumed bacterial infections (0.9 to 1.1), presumed viral infections (0.1 to 3.3), and infections of unknown cause (0.1 to 1.8). In all febrile children, antibiotic prescriptions were appropriate in 65.0% of prescriptions, inappropriate in 12.5% (range across EDs: 0.6%-29.3%), and inconclusive in 22.5% (range across EDs: 0.4%-60.8%). Prescriptions were of inappropriate duration in 20% of oral prescriptions (range across EDs: 4.4%-59.0%). Oral prescriptions were not concordant with the local guideline in 22.3% (range across EDs: 11.8%-47.3%) of prescriptions in uncomplicated RTIs and in 45.1% (range across EDs: 11.1%-100%) of prescriptions in uncomplicated urinary tract infections. A limitation of our study is that the included EDs are not representative of all febrile children attending EDs in that country. In this study, we observed wide variation between European EDs in prescriptions of antibiotics and broad-spectrum antibiotics in febrile children. Overall, one-third of prescriptions were inappropriate or inconclusive, with marked variation between EDs. Until better diagnostics are available to accurately differentiate between bacterial and viral aetiologies, implementation of antimicrobial stewardship guidelines across Europe is necessary to limit antimicrobial resistance.

Prediction of emergency department volume and severity during a novel virus pandemic: Experience from the COVID-19 pandemic.

BackgroundDuring a novel virus pandemic, predicting emergency department (ED) volume is crucial for arranging the limited medical resources of hospitals for balancing the daily patient- and epidemic-related tasks in EDs. The goal of the current study was to detect specific patterns of change in ED volume and severity during a pandemic which would help to arrange medical staff and utilize facilities and resources in EDs in advance in the event of a future pandemic.MethodsThis was a retrospective study of the patients who visited our ED between November 1, 2019 and April 30, 2020. We evaluated the change in ED patient volume and complexity of patients in our medical record system. Patient volume and severity during various periods were identified and compared with data from the past 3 years and the period that SARS occurred.ResultsA reduction in ED volume was evident. The reduction began during the early epidemic period and increased rapidly during the peak period of the epidemic with the reduction continuing during the late epidemic period. No significant difference existed in the percentages of triage levels 1 and 2 between the periods. The admission rate, length of stay in the ED, and average number of patients with out-of-hospital cardiac arrest increased during the epidemic periods.ConclusionA significant reduction in ED volume during the COVID-19 pandemic was noted and a predictable pattern was found. This specific change in pattern in the ED volume may be useful for performing adjustments in EDs in the future during a novel virus pandemic. The severity of patients visiting the ED during epidemic periods was inconclusive.

Impact of the COVID-19 pandemic on emergency department: Early findings from a hospital in Madrid

IntroducciónSARS-CoV-2, responsable de la enfermedad por coronavirus 2019 (COVID-19), fue detectado por primera vez en España el 31 de enero de 2020. El 14 de marzo fue declarado el estado de alarma con el objetivo de controlar la pandemia. El objetivo de este estudio es analizar las consecuencias de esta crisis sanitaria sobre el patrón de demanda asistencial, así como el manejo y las características de los pacientes con sospecha de COVID-19 en el Servicio de Urgencias Pediátricas.Pacientes y métodosEstudio retrospectivo observacional en niños y adolescentes menores de 18 años, atendidos en nuestro Servicio de Urgencias Pediátricas durante el periodo comprendido desde el 14 de marzo hasta el 17 de abril de 2020.ResultadosDurante el periodo de estudio se atendieron 1.666 pacientes, un 65,4% menos que en el mismo periodo de 2019. La edad media fue de 5,4 años y el 51,2% eran varones. El 39,9% fueron clasificados con niveles de alta prioridad, un 6,5% más que en 2019. Los principales motivos de consulta fueron fiebre (26,5%), síntomas respiratorios (16,1%) y traumatismos (15,2%). Un total de 218 pacientes (13%) fueron diagnosticados de posible COVID-19, confirmándose la infección en el 18,4%. El 44% (96/218) fueron diagnosticados de infección respiratoria inferior y el 33,9% (74/218), superior. El 23,8% (52/218) fueron hospitalizados.ConclusionesDurante el brote epidémico SARS-CoV-2 disminuyó la demanda de asistencia pediátrica urgente, aumentando la proporción de casos con niveles de triaje de alta prioridad. La mayoría de los pacientes con sospecha o confirmación microbiológica de COVID-19 cursaron con clínica respiratoria leve.

Prognostic performance of peripheral perfusion index and shock index combined with ESI to predict hospital outcome

IntroductionPeripheral perfusion index (PPI) and shock index (SI) are considered valuable predictors of hospital outcome and mortality in various operative and intensive care settings. In the present study, we evaluated the prognostic capabilities of these parameters for performing emergency department (ED) triage, as represented by the emergency severity index (ESI). MethodsThis prospective cross-sectional study included 367 patients aged older than 18 years who visited the ED of a tertiary referral hospital. The ESI triage levels with PPI, SI, and other basic vital sign parameters were recorded for each patient. The hospital outcome of the patients at the end of the ED period, such as discharge, admission to the hospital and death were recorded. ResultsA total of 367 patients (M/F: 178/189) admitted to the ED were categorized according to ESI and included in the study. A decrease in diastolic BP, SpO2 and PPI increased the likelihood of hospitalization and 30-day mortality. Based on univariate analysis, a significant improvement in performance was found by using age, diastolic BP, mean arterial pressure, SpO2, SI and PPI in terms of predicting high acuity level patients (ESI < 3). In the multivariable analysis only SpO2 and PPI were found to predict ESI < 3 patients. ConclusionPeripheral perfusion index and SI as novel triage instruments might provide useful information for predicting hospital admission and mortality in ED patients. The addition of these parameters to existing triage instruments such as ESI could enhance the triage specificity in unselected patients admitted to ED.