Triage Level Research Articles

40 Trajectories of Vital Signs and Risk of Cardiac Arrest in the Emergency Department

Early recognition and prevention have been added as the first link in the Chain of Survival for in-hospital cardiac arrest (IHCA). However, little is known about the trajectories of vital signs prior to IHCA, which could inform the heterogeneous processes preceding this devastating event. Therefore, using group- based trajectories modeling of longitudinal vital sign data in the emergency department (ED), we aimed to identify clinically relevant subphenotypes at high risk of IHCA in the ED. This retrospective cohort study used electronic clinical warehouse data from a tertiary medical center with approximately 100, 000 ED visits per year. We retrieved data from 733, 398 ED visits over a 7-year period. We selected one ED visit per person and excluded out-of-hospital cardiac arrest, patients aged less than 18 years, or those who had less than three vital-sign measurements. Patient demographics, triage data, vital signs (systolic blood pressure [SBP], heart rate [HR], body temperature, respiratory rate, oxygen saturation), selected laboratory test results, and IHCA status were also retrieved. Group-based trajectory modeling was performed to identify vital-sign trajectory groups, and patient characteristics and IHCA status were compared between the groups. A total of 37, 697 adult ED patients were included. Of them, 145 (0.4%) developed IHCA. Three to four trajectory groups per vital sign were identified, and the following five trajectory groups were associated with a higher rate of IHCA: low and fluctuating SBP, high and fluctuating HR, persistent hypothermia, initially resolving but recurring tachypnea, and low and fluctuating oxygen saturation. Except for the persistent hypothermia group, the other four trajectory groups were more likely to have fever and higher levels of lactic acid, C-reactive protein, and D-dimer. Within each vital sign, the IHCA-prone trajectory group was associated with a higher triage level and a higher mortality rate, compared to other trajectory groups. We identified five novel subphenotypes associated with a higher likelihood of IHCA, with some distinct patterns in clinical course and laboratory test results. A better understanding of the pre-IHCA vital sign trajectories may potentially reverse clinical deterioration and reduce IHCA in the ED.

Mortality Rate of Trauma Patients with ESI Triage Level 1-2 Who Underwent Computerized Tomography-PANSCAN versus Conventional Computerized Tomography Scan.

ObjectiveThe treatment of severe trauma patients requires a fast and accurate method to diagnose life-threatening conditions. Computerized tomography (CT)-PANSCAN has been widely used for the last 20 years to diagnose many patients in critical condition. However, no research has been performed into the efficacy of CT-PANSCAN. This research aims to compare the mortality rate of trauma patients who underwent CT-PANSCAN versus conventional CT scan.MethodsThis retrospective cohort study enrolled patients who were at triage ESI level 1–2 in the emergency department of Ramathibodi Hospital from January 2013 to December 2018 and analyzed the mortality rate between those who underwent CT-PANSCAN and conventional CT scan.ResultsThe study enrolled 123 trauma patients; 61 patients underwent CT-PANSCAN, whereas 62 patients underwent conventional CT scan. There were 1 and 7 patients who expired in the CT-PANSCAN and conventional CT scan groups, respectively. After multivariate regression analysis, the result revealed that patients who underwent CT-PANSCAN had a lower mortality rate (adjusted odds ratio = 0.023; p-value = 0.018; 95% CI 0.001–0.518).ConclusionUndergoing a CT-PANSCAN can reduce the mortality rate in trauma patients, especially in ESI level 1, 2 traumatic patients, and CT-PANSCAN available facilities.

It's Time to Provide Evidence-Based Care to Individuals with Sickle Cell Disease: A Call to Action

In the current issue of the Journal of Emergency Nursing, Linton et al1 report on their successful implementation of a clinical support tool (a banner to recommend emergency severity index [ESI] triage level 2) to improve the care of sickle cell disease (SCD) for individuals presenting to the emergency department with severe pain referred to as vaso-occlusive crisis (VOC). The researchers and clinical team are to be commended. The correct assignment of a high priority triage level is evidence-based and important to facilitate rapid placement in a treatment area to expedite pain management.

1390Utilisation of hospital Services during COVID 19 Pandemic in New Zealand

Abstract Background Many factors have impacted the use of hospital services during the COVID-19 pandemic. This work described the volume and pattern changes of emergency department (ED) and inpatient admissions during earlier pandemic period in New Zealand in 2020. Methods ED and inpatient admissions during the pandemic period were compared with the figures and characteristics in the same time period in the previous years Results Over the period, ED and inpatient admissions decreased by 25 and 20 percent respectively. Remarkable declines of 41% in ED and 40% in inpatient were observed during the alert level 4 lockdown period. In the ED admissions, the degree of the decline was higher in less urgent presentations (triage levels 4 and 5), young patients (aged 0-24 years) and the patients without long term conditions. In the inpatient admissions, the degree of the decline was higher in the patients with lower level of inpatient clinical complexity, young patients and the admissions of respiratory diseases (especially influenza), viral infections, and injuries due to traffic and sport accident. In contrast, some hospitalisations increased during the period, including alcohol-related ED presentations, bacterial infections and injuries related to falls and assault occurred in home. Conclusions The changes in hospitalisation utilisation are likely associated with the changes in people’s behaviour in seeking health services, in behaviours of health risk or protective factors, and the changes in healthcare provided to the population during the period. Key messages The results provide insights for further assessment of health needs and health services.

The acceptability and safety of video triage for ambulance service patients and clinicians during the COVID-19 pandemic.

Introduction:In response to anticipated challenges with urgent and emergency healthcare delivery during the early part of the COVID-19 pandemic, Yorkshire Ambulance Service NHS Trust introduced video technology to supplement remote triage and ‘hear and treat’ consultations as a pilot project in the EOC. We conducted a service evaluation with the aim of investigating patient and staff acceptability of video triage, and the safety of the decision-making process.Methods:This service evaluation utilised a mixture of routine and bespoke data collection. We sent postal surveys to patients who were recipients of a video triage, and clinicians who were involved in the video triage pilot logged calls they attempted and undertook.Results:Between 27 March and 25 August 2020, clinicians documented 1073 triage calls. A successful video triage call was achieved in 641 (59.7%) cases. Clinical staff reported that video triage improved clinical assessment and decision making compared to telephone alone, and found the technology accessible for patients. Patients who received a video triage call and responded to the survey (40/201, 19.9%) were also satisfied with the technology and with the care they received. Callers receiving video triage that ended with a disposition of ‘hear and treat’ had a lower rate of re-contacting the service within 24 hours compared to callers that received clinical hub telephone triage alone (16/212, 7.5% vs. 2508/14349, 17.5% respectively).Conclusion:In this single NHS Ambulance Trust evaluation, the use of video triage for low-acuity calls appeared to be safe, with low rates of re-contact and high levels of patient and clinician satisfaction compared to standard telephone triage. However, video triage is not always appropriate for or acceptable to patients and technical issues were not uncommon.

Changes in Emergency Department Volumes at the Largest U.S. Military Hospital During the COVID-19 Pandemic.

The coronavirus-2019 (COVID-19) pandemic has significantly impacted global healthcare delivery. Brooke Army Medical Center (BAMC) is the DoD's largest hospital and a critical platform for maintaining a ready medical force. We compare temporal trends in patient volumes and characteristics in the BAMC emergency department (ED) before versus during the pandemic. We abstracted data on patient visits from the BAMC ED electronic medical record system. Data included patient demographics, visit dates, emergency severity index triage level, and disposition. We visually compared the data from January 1, 2019 to November 30, 2019 versus January 1, 2020 to November 30, 2020 to assess the period with the most apparent differences. We then used descriptive statistics to characterize the pre-pandemic control period (1 March-November 30, 2019) versus the pandemic period (1 March-November 30, 2020). Overall, when comparing the pre-pandemic and pandemic periods, the median number of visits per day was 232 (Interquartile Range (IQR) 214-250, range 145-293) versus 165 (144-193, range 89-308, P < .0001). Specific to pediatric visits, we found the median number of visits per day was 39 (IQR 33-46, range 15-72) versus 18 (IQR 14-22, range 5-61, P < .001). When comparing the median number of visits by month, the volumes were lower during the pandemic for all months, all of which were strongly significant (P < .001 for all). The BAMC ED experienced a significant decrease in patient volume during the COVID-19 pandemic starting in March 2020. This may have significant implications for the capacity of this facility to maintain a medically ready force.

Prehospital Disaster Triage Does Not Predict Pediatric Outcomes: Comparing the Criteria Outcomes Tool to Three Mass-Casualty Incident Triage Algorithms.

It remains unclear which mass-casualty incident (MCI) triage tool best predicts outcomes for child disaster victims. The primary objective of this study was to compare triage outcomes of Simple Triage and Rapid Treatment (START), modified START, and CareFlight in pediatric patients to an outcomes-based gold standard using the Criteria Outcomes Tool (COT). The secondary outcomes were sensitivity, specificity, under-triage, over-triage, and overall accuracy at each level for each MCI triage algorithm. Singleton trauma patients under 16 years of age with complete prehospital, emergency department (ED), and in-patient data were identified in the 2007-2009 National Trauma Data Bank (NTDB). The COT outcomes and procedures were translated into ICD-9 procedure codes with added timing criteria. Gold standard triage levels were assigned using the COT based on outcomes, including mortality, injury type, admission to the hospital, and surgical procedures. Comparison triage levels were determined based on algorithmic depictions of the three MCI triage tools. A total of 31,093 patients with complete data were identified from the NTDB. The COT was applied to these patients, and the breakdown of gold standard triage levels, based on their actual clinical outcomes, was: 17,333 (55.7%) GREEN; 11,587 (37.3%) YELLOW; 1,572 (5.1%) RED; and 601 (1.9%) BLACK. CareFlight had the best sensitivity for predicting COT outcomes for BLACK (83% [95% confidence interval, 80%-86%]) and GREEN patients (79% [95% CI, 79%-80%]) and the best specificity for RED patients (89% [95% CI, 89%-90%]). Among three prehospital MCI triage tools, CareFlight had the best performance for correlating with outcomes in the COT. Overall, none of three tools had good test characteristics for predicting pediatric patient needs for surgical procedures or hospital admission.

Improvement the Healthcare Quality of Emergency Department after the Cloud-Based System of Medical Information-Exchange Implementation.

Background: The National Health Insurance has been implemented in Taiwan since 1995. The government established a medical information-exchange system to reduce duplicate medications and examinations, which have inhibited healthcare expenditures. The potential benefit of medical information exchange about healthcare quality in emergency departments (ED) was worthy of evaluating; Methods: The inquiry rate of cloud data for patients’ information in Taiwanese National Health Insurance Administration was defined as a factor, and the healthcare quality included the ratio of staying more than 48 h in the ED and the hospitalization rate within 8 h from ED by triage levels of 1, 2, and 3 in different levels of hospitals from 2013 to 2019. Poisson regression analysis was used to quantify time trends of the query rate of the MediCloud system, the rate of staying more than 48 h in ED, admission rate within 8 h in ED, and the effect of healthcare quality in ED after MediCloud system implementation; Results: The health information exchange decreased the rate of staying over 48 h in the ED of medical centers. It also improved the early hospitalization of urgent ED patients in regional hospitals; Conclusions: Through medical information exchange to understand patients’ current conditions, we can reduce crowding in the ED of medical centers and facilitate rapid hospitalization of urgent patients in regional hospitals. According to these findings, the government should establish medical information exchange to improve the healthcare quality of ED.

Resource Utilization During Low-Acuity Pediatric Emergency Department Visits.

The aims of the study were to estimate testing and treatment rates among pediatric low-acuity emergency department (ED) visits and to compare testing and treatment patterns at general and pediatric-specific EDs. We performed a cross-sectional study of triage level 4 or 5 pediatric visits from a complex survey of nonfederal US EDs from 2008 to 2017. We analyzed demographics, vital signs, disposition, testing, and treatment. We calculated proportions for each data element and used χ2 tests to determine differences between general and pediatric EDs. There were an estimated 306.2 million pediatric visits with 129.1 million acuity level 4 or 5 visits (57.2%; 95% confidence interval, 55.4%-58.9%), with diagnostic testing performed in 47.1% and medications administered in 69.6% of the visits. Most low-acuity visits (82.0%) were to general EDs. Tests performed more frequently in general EDs compared with pediatric EDs included radiographs (25.8% vs 15.7%, P < 0.01), complete blood count (6.4% vs 3.9%, P < 0.01), electrolytes (11.6% vs 3.7%, P < 0.01), and glucose (2.0% vs 0.9%, P < 0.01). Ultrasound was used less frequently in general EDs (0.5 vs 0.7, P < 0.01). There were similar rates of intravenous fluid and overall medication administration and a higher proportion of patients receiving antibiotics in general EDs (28.7% vs 23.8%, P < 0.01). More than half of pediatric visits to the ED are low acuity. Although general EDs relied on more imaging, blood testing and antibiotics, and pediatric EDs on ultrasound, overall resource utilization was high in this population across both ED types and can likely be reduced.

Documentation of Shared Decisionmaking in the Emergency Department

While patient-centered communication and shared decisionmaking are increasingly recognized as vital aspects of clinical practice, little is known about their characteristics in real-world emergency department (ED) settings. We constructed a natural language processing tool to identify patient-centered communication as documented in ED notes and to describe visit-level, site-level, and temporal patterns within a large health system. This was a 2-part study involving (1) the development and validation of an natural language processing tool using regular expressions to identify shared decisionmaking and (2) a retrospective analysis using mixed effects logistic regression and trend analysis of shared decisionmaking and general patient discussion using the natural language processing tool to assess ED physician and advanced practice provider notes from 2013 to2020. Compared to chart review of 600 ED notes, the accuracy rates of the natural language processing tool for identification of shared decisionmaking and general patient discussion were 96.7% (95% CI 94.9% to 97.9%) and 88.9% (95% confidence interval [CI] 86.1% to 91.3%), respectively. The natural language processing tool identified shared decisionmaking in 58,246 (2.2%) and general patient discussion in 590,933 (22%) notes. From 2013 to 2020, natural language processing-detected shared decisionmaking increased 300% and general patient discussion increased 50%. We observed higher odds of shared decisionmaking documentation among physicians versus advanced practice providers (odds ratio [OR] 1.14, 95% CI 1.07 to 1.23) and among female versus male patients (OR 1.13, 95% CI 1.11 to 1.15). Black patients had lower odds of shared decisionmaking (OR 0.8, 95% CI 0.84 to 0.88) compared with White patients. Shared decisionmaking and general patient discussion were also associated with higher levels of triage and commercial insurance status. In this study, we developed and validated an natural language processing tool using regular expressions to extract shared decisionmaking from ED notes and found multiple potential factors contributing to variation, including social, demographic, temporal, and presentation characteristics.

Predictive value of HEART score in the outcome of acute coronary syndrome and disposition

Objective: Disposition in acute coronary syndrome (ACS) is pivotal in an emergency department (ED). HEART score is a recent scoring system for finding primary endpoints in undetermined ACS. This study aimed at evaluating the predictive value of HEART score in ACS outcome and disposition. Methods: In this prospective study, all patients with chest pain presentation compatible with our inclusion criteria referring to ED were enrolled during one year. Demographic data, triage level, hospital length of stay, admission ward, coronary angiography result, HEART score, thrombolysis in myocardial infarction (TIMI) score, 1-month primary ACS endpoints and major adverse cardiac events (MACE) were evaluated. Results: In our studied population (200 cases), 49 patients (24.5%) had at least one score for MACE. Comparing the prognostic values of TIMI vs HEART score in MACE revealed that the HEART had a larger AUC. The best cut-off point of HEART score in MACE prediction was calculated to be ≥5. There was a statistically significant relation between HEART score and hospital length of stay. The higher the HEART score, the more probability of patients being admitted to either hospital cardiac ward or coronary care unit (CCU). There was a significant relationship between the triage level and HEART score. Patients with higher HEART score had more acuity (lower triage level 1 or 2). Conclusion: HEART predicted MACE better than TIMI in low risk ACS. Patients with higher HEART score were more admitted to the hospital with longer hospital stay and patients with lower HEART score had higher triage level with less acuity.

English

BACKGROUND Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) carries a significant morbidity and mortality with a need for frequent hospitalizations and mechanical ventilation. Thus, a model was searched that required simple information that was consistently available in emergency department, upon the presentation of the patient which allowed risk stratification and to identify patients who might potentially benefit from early intervention. METHODS This was a prospective observational study conducted over a period of 6 months, from May 2018 to December 2018 with a study sample of 136 patients. The primary objective was aimed to validate the BAP-65 score system in predicting the need for ventilatory support and mortality in patients who presented with acute exacerbation of COPD. RESULTS Mean age of the study population was 64.13 ± 9.7 and 29 (21.32 %) were females with obvious male predominance. It was observed that as the BAP-65 score increases, the mortality increases. Mortality among the score groups 0, 1 and 2 was one, zero, one respectively. The mortality is about 37.5 % in the score group 3 and it increased to 90.9 % in the score group 4. The patients who needed mechanical ventilation were about 4 % in the score group 2 and it increased to 100 % in the score group 4. BAP-65 scoring system had a sensitivity of 88.89 % and specificity of 90.68 % in predicting the in-hospital mortality, and a sensitivity of 84 % and specificity of 94.59 % in predicting the need for mechanical ventilation during hospital stay. CONCLUSIONS The BAP-65 scoring system seems to be a promising tool which is simple and accurate. The score correlated well with both the mortality and also the need for mechanical ventilation, thus helping in decision making at triage level and also in prognostication of the disease. KEYWORDS Chronic Obstructive Pulmonary Disease, Acute Exacerbation, BAP-65, AECOPD, Mortality, Mechanical Ventilation

يافته هاي الكتروكارديوگرافي مرتبط با ايسكمي ميوكارد در بيماران با علايم غير قلبي مراجعه كننده به اورژانس نمازي در سال 1397

Introduction: Silent myocardial ischemia is defined as the presence of objective evidence of cardiac ischemia in the absence of chest discomfort or one of the symptoms equivalent to angina. The aim of this study was to evaluate the electrocardiography (ECG) findings related to cardiac ischemia in non-cardiac patients with suspected silent myocardial ischemia referring to the emergency department. Methods: This retrospective cross-sectional study (March 2018-March 2019) was conducted on adult patients with non-cardiac complaints referring to the Emergency Department of Shiraz Namazi Hospital, southern Iran, with triage levels 1 and 2, who were suspected to have silent myocardial ischemia, and underwent ECG and two troponin tests after admission. Patients with trauma, triage levels 3-5, those with typical chest pain, and patients with diagnosis of ST-Elevation Myocardial Infarction (STEMI) were excluded from the survey. Demographic data, the results of two troponin tests, and cardiac ischemia-related findings on ECG, including ST depression and T inversion, were evaluated. Then, the data were statistically analyzed using SPSS version 16 and descriptive and analytical statistical tests. Results: Overall, 180 patients were enrolled. The mean (± standard deviation) of patients’ age was 69.3±15.01 years. 92 patients (51.1%) were male. ST depression and T inversion were found in ECG of 90 (50.0%) and 88 (48.9%) patients, respectively. ST depression and/or T inversion was observed in 168 (93.3%) patients. There was no statistically significant relationship between mean age, gender, and cause of referral with ST depression or T inversion. Two positive troponin test results were observed in 23 (12.8%) and both tests were negative in 59.4% of patients. There was no statistically significant relationship between having at least one positive troponin test and having ST depression or T inversion findings (P-value=0.56 and P-value=0.90, respectively). Conclusion: ST depression and T inversion were present in ECG of half of the patients. Two positive troponin and both negative tests were observed in 23 (12.8%) and 59.4% of patients, respectively. This finding indicates that the matching of ECG findings and multistage troponin test is great important in the final diagnosis of cardiac ischemia, however, ECG changes in patients with non-cardiac complaints do not necessarily is indicated the myocardial infarction.

Validation of the Pediatric Canadian Triage and Acuity Scale at the Emergency Department of a Tertiary Children's Hospital in Costa Rica.

Background: The Pediatric Canadian Triage and Acuity Scale (PedCTAS) is a recognized system that prioritizes care by the severity of illness. The goal of this study was to describe and analyze the results from the implementation of the PedCTAS in a tertiary children’s hospital in Costa Rica.Methods: This was a retrospective observational study of children presenting to the emergency department (ED) from 1st January to 31st December of 2019 in the only children’s hospital in Costa Rica. Outcome measures were hospitalization, ICU admission, waiting times from triage to physician time (TPT), left without being seen (LWBS), length of stay (LOS), in relation to the triage level, and final disposition.Results: A total of 93,001 patients were admitted to the ED. The proportion for hospitalizations according to triage category was 85.3%, 40%, 14%, 4.3%, and 2% for patients triaged at CTAS levels I, II, III, IV, and V respectively. A total of 2045 (2.19%) patients were LWBS. Some 585 (0.62%) patients were admitted to ICU. Median TPT for each category was for levels I:12 min, II:20 min, III:22 min, IV:34 min, and V:54 min. The LOS in the ED patients triaged as levels I and II stayed longer and the mortality rate was also higher in patients classified as levels I and II. The mortality rate was for level I patients 44.2% (23 patients) and level II 1.4% (8 patients).Conclusions: This study shows evidence of validation of the PedCTAS in a developing country in Latin America. Implementation of a validated triage tool in our country helps us to provide improvements in the care of pediatric patients in the ED.

An updated national survey of triage and triage related work in Sweden: a cross-sectional descriptive and comparative study

BackgroundTriage and triage related work has been performed in Swedish Emergency Departments (EDs) since the mid-1990s. According to two national surveys from 2005 to 2011, triage was carried out with different triage scales and without guidelines or formal education. Furthermore, a review from 2010 questioned the scientific evidence for both triage as a method as well as the Swedish five level triage scale Medical Emergency Triage and Treatment System (METTS); nevertheless, METTS was applied in 65% of the EDs in 2011. Subsequently, METTS was renamed to Rapid Emergency Triage and Treatment System (RETTS©). The hypothesis for this study is that the method of triage is still applied nationally and that the use of METTS/RETTS© has increased. Hence, the aim is to describe the occurrence and application of triage and triage related work at Swedish Emergency Departments, in comparison with previous national surveys.MethodsIn this cross-sectional study with a descriptive and comparative design, an electronic questionnaire was developed, based on questionnaire from previous studies. The survey was distributed to all hospital affiliated EDs from late March to the middle of July in 2019. The data was analysed with descriptive statistics, by IBM SPSS Statistics, version 26.ResultsOf the 51 (75%) EDs partaking in the study, all (100%) applied triage, and 92% used the Swedish triage scale RETTS©. Even so, there was low concordance in how RETTS© was applied regarding time frames i.e., how long a patient in respective triage level could wait for assessment by a physician. Additionally, the results show a major diversion in how the EDs performed education in triage.ConclusionThis study confirms that triage method is nationally implemented across Swedish EDs. RETTS© is the dominating triage scale but cannot be considered as one triage scale due to the variation with regard to time frames per triage level. Further, a diversion in introduction and education in the pivotal role of triage has been shown. This can be counteracted by national guidelines in what triage scale to use and how to perform triage education.

Factors associated with a high-risk return visit to the emergency department: a case-crossover study.

Although factors related to a return emergency department (ED) visit have been reported, few studies have examined 'high-risk' return ED visits with serious adverse outcomes. Understanding factors associated with high-risk return ED visits may help with early recognition and prevention of these catastrophic events. We aimed to (1) estimate the incidence of high-risk return ED visits, and (2) to investigate time-varying factors associated with these revisits. Case-crossover study. We used electronic clinical warehouse data from a tertiary medical center. We retrieved data from 651 815 ED visits over a 6-year period. Patient demographics and computerized triage information were extracted. A high-risk return ED visit was defined as a revisit within 72 h of the index visit with ICU admission, receiving emergency surgery, or with in-hospital cardiac arrest during the return ED visit. Time-varying factors associated with a return visit were identified. There were 440 281 adult index visits, of which 19 675 (4.5%) return visits occurred within 72 h. Of them, 417 (0.1%) were high-risk revisits. Multivariable analysis showed that time-varying factors associated with an increased risk of high-risk revisits included the following: arrival by ambulance, dyspnea, or chest pain on ED presentation, triage level 1 or 2, acute change in levels of consciousness, tachycardia (>90/min), and high fever (>39°C). We found a relatively small fraction of discharges (0.1%) developed serious adverse events during the return ED visits. We identified symptom-based and vital sign-based warning signs that may be used for patient self-monitoring at home, as well as new-onset signs during the return visit to alert healthcare providers for timely management of these high-risk revisits.

Evaluating delays for emergent CT scans from a rural British Columbia hospital.

Computed Tomography (CT) scans help diagnose and triage life-threatening and time-sensitive emergency conditions, but most rural hospitals in British Columbia do not have access to a local CT scanner. We investigate how many transfers from a rural British Columbia hospital were for CT scans and describe the time delays to emergent CT imaging. This was a prospective cohort study, over a 1-year period, on all patients requiring a transfer from the Golden and District Hospital, located 247km from the closest CT scanner. Data collection forms were completed prospectively and the main measurements included age, transport triage level, reason for transfer, referral hospital, transfer request time, and CT scan time. The time interval between the CT request and CT imaging was calculated and represents the 'delay to CT scan' interval. The study hospital received 8672 emergency department (ED) visits and 220 were transferred to referral centres (2.5%). 61% of all transfers received a CT scan. Transfers for time-sensitive emergencies took an average of 6h 52min. Patients with acute stroke experienced a 4h 44min time interval. Less urgent and non-urgent conditions entailed an even greater time delay. This study highlights that the lack of a rural CT scanner is associated with increased transfers and significant time delays. Improving access to CT scanners for rural communities may be one of the many steps in addressing healthcare disparities between rural and urban communities.

بررسی وضعیت انتقال درون بیمارستانی بیماران ترومایی اورژانس؛ یک مطالعه مقطعی

Introduction: Trauma patients are the main emergency visitors in need of in-hospital transfer, who are exposed to a wide range of complications. This study was performed to evaluate intra-hospital transportation of trauma patients using a checklist. Methods: This cross-sectional study was performed in AlGhadir Hospital, Abhar, Iran, from 2020 to 2021, on 216 adult trauma patients with triage levels 1, 2 and 3, who needed to be transferred to other wards or required transportation for undergoing diagnostic and therapeutic measures. Evaluations were made before, during, and after the transfer and the results and complications of transportation in these three stages were compared. Results: In this study, 216 patients with an average age of 18.9 ± 70.3 years were examined. Most of the admitted patients were male (74.1%), with emergency referral (83.3%), and presented following an accident (68.1%). Most transportations were performed for diagnostic purposes (52.3%) and in those with triage level 2 (69.4%). The transfer quality score was calculated to be 93.99% before the transfer, 84.65% during the transfer, and 91.02% after the transfer. Complications were observed in 14.36% of transfers, which included hypotension or hypertension, drop in arterial oxygen pressure, and hypothermia. In addition, most errors had occurred during the transfer and were related to not using monitoring (18.1%), pulse oximetry (17.6%), and not checking peripheral vein line (13.9%). The errors that occurred during the pre-transfer phase included not using pulse oximetry, monitoring, and face mask (1.9%) and those occurring in the post-transfer phase were not controlling Foley and nasogastric catheters (0.5%). Conclusion: The findings of the study showed that the incidence rate of complications is high, especially during transfer. This can be used in analyzing the causes of errors and planning to increase the safety level of patients. Identification and management of risk factors in the transportation process ensures the safety of patients.

Characteristics of visits and predictors of admission from a paediatric emergency room in Saudi Arabia

BackgroundThe Emergency Room (ER) is one of the most used areas in healthcare institutions. Problems with over utilisation and overcrowding have been reported worldwide. This study aims at examining the characteristics of paediatric ER visits, the rate of hospital admissions and its associated predictors at King Fahd Hospital of the University in the Eastern Province of Saudi Arabia.MethodsThis is a retrospective, medical record-based study. Variables included gender, age group, nationality, complaints, Triage level, shifts and seasons. Descriptive statistics were reported as frequencies/percentages. P-values were obtained through a Chi-Squared test while unadjusted and adjusted odds ratios were estimated by binary logistic regression, where admission was considered as the outcome.ResultsThe total number of paediatric patients included was 46,374, and only 2.5% were admitted. Males comprised 55.4% while females comprised 44.6%. The most common age group were toddlers, and 92.4% of the total sample were Saudis. The most common complaint was fever (26.9%) followed by respiratory symptoms (24.9%). Only 7 patients (0.02%) were classified as triage I (Resuscitation), and most were triage IV (Less urgent) (71.0%). Most visits occurred during the winter months. Adjusted ORs showed that neonates had higher odds of admission (OR = 3.85, 95%CI = 2.57–5.76). Moreover, those presenting with haematological conditions showed an OR of 65.49 (95%CI = 47.85–89.64), followed by endocrine conditions showing an OR of 34.89 (95%CI = 23.65–51.47). Triage I had a very high odds of admission (OR = 19.02, 95%CI = 2.70–133.76), whereas triage V was associated with a very low odds of admission (OR = 0.30, 95%CI = 0.23–0.38).ConclusionsA low rate of hospital admission was found in comparison with other rates worldwide. This was mostly attributed to an alarmingly high number of non-urgent ER visits. This further emphasises the problem with improper use of ER services, as these cases should be more appropriately directed towards primary healthcare centres. Further studies to examine the impact of prioritising patients in the ER based on the identified predictors of hospital admission, in addition to the standard triage system, are suggested.

The new emergency department “Tuscan triage System”. Validation study

IntroductionA new organizational framework was recently implemented in Tuscan Emergency Departments (EDs), including specific low-priority streaming. A new ED triage system, named “Tuscan Triage System” (TTS), was devised with the purpose of applying this reorganization. MethodsA validation study was designed with the primary aims of assessing the content, face, and criterion validities, and the inter-rater reliability of the TTS. The secondary aim was to estimate the differences in triage level assignation between the previous “Regional Triage System” (RTS) and the TTS. Twenty-four nurses trained for the TTS were enrolled to assign TTS priority levels to 100 triage clinical case vignettes drawn up by the developers of the TTS (reference standard). ResultsThe Content Validity Index – Scale/Average (S-CVI/Ave) of TTS was 0.98. Concerning to face validity, the S-CVI/Ave was 1. The highest adherence of triage level assignation to the reference standard was for levels 1 and 2. The Krippendorff α value was 0.808. Undertriage and overtriage were 10.45% and 14.29%, respectively. Overall, the comparation between RTS and TTS showed a marked shift of level assignation towards TTS low priority levels. ConclusionsThe TTS seems to be safe. These results should be confirmed through studies in the real clinical settings.