Triage Level Research Articles

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.

A Descriptive Analysis of the Cumulative Experiences of Emergency Medicine Residents in the Pediatric Emergency Department.

Most children seeking emergency care are evaluated in general emergency departments (EDs). The cumulative pediatric clinical experiences of emergency medicine (EM) residents are largely unknown. This study examined EM resident pediatric clinical experience through the lens of the Accreditation Council for Graduate Medical Education requirements and the Model of the Clinical Practice of Emergency Medicine. Retrospective, observational study of the cumulative clinical experience of two classes of EM residents from a 4-year training program at two pediatric EDs of a quaternary care pediatric center. A database of resident patient encounters was generated from the electronic medical record. Experiences classified included: diagnosis categories per the Model of the Clinical Practice of Emergency Medicine, procedures, and resuscitations. Results were stratified by age, acuity, and disposition. Twenty-five EM residents evaluated 17,642 patients (median= 723). Most patients (73.5%) were emergent acuity (Emergency Severity Index triage level 2 or 3 or non-intensive care admission); 2% were critical. Residents participated in 598 (median= 22) medical resuscitations and 483 (median= 19) trauma resuscitations. Minor procedures (e.g., laceration repair) were commonly performed; critical procedures (e.g., intubation) were rare. Exposure to neonates was infrequent and pediatric deaths were rare. Abdominal pain (5.7%), asthma exacerbation (4.6%), and fever (3.8%) were the most common diagnoses. Emergency medicine residents encountered a wide array of pediatric diagnoses throughout training and performed a substantial number of common pediatric procedures. Exposure to critical acuity and procedures, neonatal pathology, and certain pediatric-specific diagnoses, such as congenital heart disease, was limited despite training in a large, quaternary care children's hospital. Curriculum development and collaboration should focus on these areas.

Choosing and Doing wisely: triage level I resuscitation a possible new field for starting palliative care and avoiding low-value care \u2013 a nationwide matched-pair retrospective cohort study in Taiwan

BackgroundThe association between palliative care and life-sustaining treatment following emergency department (ED) resuscitation is unclear. This study aims to analyze the usage of palliative care and life-sustaining treatments among ED triage level I resuscitation patients based on a nationally representative sample of patients in Taiwan.MethodsA matched-pair retrospective cohort study was conducted to examine the association between palliative care and outcome variables using multivariate logistic regression and Kaplan–Meier survival analyses. Between 2009 and 2013, 336 ED triage level I resuscitation patients received palliative care services (palliative care group) under a universal health insurance scheme. Retrospective cohort matching was performed with those who received standard care at a ratio of 1:4 (usual care group). Outcome variables included the number of visits to emergency and outpatient departments, hospitalization duration, total medical expenses, utilization of life-sustaining treatments, and duration of survival following ED triage level I resuscitation.ResultsThe mean survival duration following level I resuscitation was less than 1 year. Palliative care was administered to 15% of the resuscitation cohort. The palliative care group received significantly less life-sustaining treatment than did the usual care group.ConclusionAmong patients who underwent level I resuscitation, palliative care was inversely correlated with the scope of life-sustaining treatments. Furthermore, triage level I resuscitation status may present a possible new field for starting palliative care intervention and reducing low-value care.

Performance of a three-level triage scale in live triage encounters in an emergency department in Hong Kong

BackgroundDespite its continued use in many low-volume emergency departments (EDs), 3-level triage systems have not been extensively studied, especially on live triage cases. We have modified from the Australasian Triage Scale and developed a 3-level triage scale, and sought to evaluate its validity, reliability, and over- and under-triage rates in real patient encounters in our setting.MethodThis was a cross-sectional study in a single ED with 24,000 attendances per year. At triage, each patient was simultaneously assessed by a triage nurse, an adjudicator (the “criterion standard”), and a study nurse independently. Predictive validity was determined by comparing clinical outcomes, such as hospitalization, across triage levels. The discriminating performance of the triage tool in identifying patients requiring earlier medical attention was determined. Inter-observer reliability between the triage nurse and criterion standard, and across providers were determined using kappa statistics.ResultsIn total, 453 triage ratings of 151 triage cases, involving 17 ED triage nurses and 57 nurse pairs, were analysed. The proportion of hospital admission significantly increased with a higher triage rating. The performance of the scale in identifying patients requiring earlier medical attention was as follows: sensitivity, 68.2% (95% CI 45.1–86.1%); specificity, 99.2% (95% CI 95.8–100%); positive predictive value, 93.8% (95% CI 67.6–99.1%); and negative predictive value, 94.8% (95% CI 90.8–97.1%). The over-triage and under-triage rates were 0.7% and 4.6%, respectively. Agreement between the triage nurse and criterion standard was substantial (quadratic-weighted kappa = 0.76, 95% CI, 0.60–0.92, p < 0.001), so was the agreement across nurses (quadratic-weighted kappa = 0.81, 95% CI 0.65–0.97, p < 0.001).ConclusionsThe 3-level triage system appears to have good validity and reasonable reliability in a low-volume ED setting. Further studies comparing 3-level and prevailing 5-level triage scales in live triage encounters and different ED settings are warranted.

LO31: Triage drift: Variation in application of the Canadian Triage Acuity Scale between triage nurses compared to triage paramedics in response to overcrowding pressures in an emergency department

Introduction: CTAS is a validated five-level triage score utilized in EDs across Canada and internationally. Moderate interrater reliability between prehospital paramedic and triage nurse application of CTAS during clinical practice has been found. This study is the first assessment of the variation in distribution of CTAS scores with increasing departmental pressure as measured by the NEDOCs scale comparing triage allocations made by triage nurses with those made by triage paramedics. Methods: We conducted a retrospective, observational cohort study of EDIS data of all patients triaged in the Halifax Infirmary Emergency Department from January 1, 2017-May 30, 2017 and January 1, 2018 - May 30, 2018. CTAS score assignment by nursing and paramedic triage staff were compared with increasing levels of ED overcrowding, as determined by the department NEDOCS score. Results: Nurses were more likely to assign higher acuity scores in all situations of department crowding; there was a 3% increased probability that a nurse, as compared to a paramedic, would triage as emergent when the ED was not overcrowded (Pearson chi-square(1) = 4.21, p &lt; 0.05, Cramer's v = 0.028, n = 5314), and a 10% increased probability that a nurse, as compared to a paramedic, would triage a patient as emergent when EDs were overcrowded (Pearson chi-square(1) = 623.83, p &lt; 0.001, Cramer's v = 0.11, n = 56 018). Conclusion: Increasing levels of ED overcrowding influence triage nurse CTAS score assignment towards higher acuity to a greater degree than scores assigned by triage paramedics.

P038: Comparison of diagnostic imaging rates between workplace and non-workplace injuries in the emergency department: a ten-year review

Background: In Canada, injuries represent 21% of Emergency Department (ED) visits. Faced with occupational injuries, physicians may feel pressured to provide urgent imaging to facilitate expedited return to work. There is not a body of literature to support this practice. Twenty percent of adult ED injuries involve workers compensation. Aim Statement: Tacit pressures were felt to impact imaging rates for patients with workplace injuries, and our aim was to determine if this hypothesis was accurate. We conducted a quality review to assess imaging rates among injuries suffered at work and outside work. A secondary aim was to reduce the harm resulting from non-value-added testing. Measures &amp; Design: Information was collected from the Emergency Department Information System on patients with acute injuries over the age of 16-years including upper limb, lower limb, neck, back and head injuries. Data included both workplace and non-work-related presentations, Canadian Triage and Acuity Scale (CTAS) levels and age at presentation. Imaging included any of X-ray, CT, MRI, or Ultrasound ordered in EDs across the central zone of Nova Scotia from July 1, 2009 to June 30, 2019. A total of 282,860 patient-encounters were included for analysis. Comparison was made between patients presenting under the Workers’ Compensation Board of Nova Scotia (WCB) and those covered by the Department of Health and Wellness (DOHW). Imaging rates for all injuries were also trended over this ten-year period. Evaluation/Results: In patients between 16 and 65-years, the WCB group underwent more imaging (55.3% of visits) than did the DOHW group (43.1% of visits). In the same cohort, there was an overall decrease of over 10% in mean imaging rates for both WBC and DOHW between the first five-year period (2009-2013) and the second five-year study period (2013-2018). Imaging rates for WCB and DOHW converged with each decade beyond 35 years of age. No comparison was possible beyond 85-years, due to the absence of WCB presentations. Discussion/Impact: Patients presenting to the ED with workplace injuries are imaged at a higher rate than those covered by the DOHW. Campaigns promoting value-added care may have impacted imaging rates during the ten-year study period, explaining the decline in ED imaging for all injuries. While this 10% decrease in overall imaging is encouraging, these preliminary data indicate the need for further education on resource stewardship, especially for patients presenting to the ED with workplace injuries.

P057: Impact of a clinical pathway for the treatment of acute asthma in the emergency department

Introduction: In Canada, acute asthma is a common cause of emergency department (ED) attendance and its treatment is affected by ED overcrowding and increasing wait times. Literature suggests that a clinical pathway (CP) for the treatment of acute asthma can increase the use of medical therapy, reduce hospital admission rates and decrease associated costs. However, only few have looked at the effect on ED length of stay (ED LOS) when such a CP is initiated by triage nurse/respiratory therapist among adults. In this optic, an asthma CP was launched on Feb. 2016 at Centre Hospitalier Universitaire de Sherbrooke (QC) and included medical directives allowing triage nurse and respiratory therapist initiation of treatment. Methods: The objectives are to determine the effect of an ED nurse/respiratory therapist-initiated asthma CP on (1) ED LOS, (2) time-to-treatment (beta-agonist, corticosteroids), time-to-MD and other secondary outcomes. This was a retrospective before-after study. Adults presenting to the ED before and after CP implementation with a final diagnosis of asthma or asthma exacerbation were eligible. The groups A (before implementation) and B (after implementation) were compared for ED LOS. Three subgroups of 50 patients were generated and compared for outcomes: A1 (before implementation), B1 (after implementation without CP) and B2 (after implementation with CP). All five groups were controlled for triage level and sex. Results: In total, 1086 patients were included; 543 before implementation (Mar. 2011 – Feb. 2016) and 543 after (Feb. 2016 – Jun. 2019), of whom 14% (N = 77) were treated by CP. The average ED LOS was similar (10.36h vs 10.65h; (p = 0,31)) in group A and in group B. In groups A1, B1 and B2, the median ED LOS were respectively 6.00, 6.84, 4.80; these differences were not statistically significant. The average time-to-treatment for beta-agonist in A1, B1 and B2 was respectively 148, 180 and 50 mins; the differences between B2 and A1 and between B2 and B1 were both statistically significant (p &lt; 0,05). Conclusion: Although this study indicates a low compliance to the CP, it shows that time-to-treatment can be reduced. It didn't demonstrate any statistically significant decrease in ED LOS, most likely due to low number of patients and non-normal distribution, but the 1.2h shorter could be a major advantage if it proves true. Further studies are essential to understand facilitators and alleviate the barriers in anticipation of a multi-centric implementation.

TNFR1 is associated with short-term mortality in patients with diabetes and acute dyspnea seeking care at the emergency department

BackgroundCirculating levels of TNF alpha receptor 1 (TNFR1) and 2 (TNFR2) are associated with increased long-term mortality and impaired kidney function.AimTo study association between circulating levels of TNFR1 and TNFR2 and short-term mortality in patients with diabetes and dyspnea.Population and methodsPatients aged ≥ 18 years seeking at emergency department (ED) during daytime on weekdays between December 2013 and July 2018, with diabetes and acute dyspnea, identified at the triage process, were included. Participants (n = 291) were triaged according to Medical Emergency Triage and Treatment System-Adult score, and blood samples were collected. Association between TNFR1 and TNFR2, respectively, and 90-day mortality were estimated by Cox regression models adjusted for age, sex, BMI, creatinine and CRP.ResultsUnivariate models showed significant associations between TNFR1 and TNFR2, respectively, and CRP, age and creatinine. TNFR1 and TNFR2 tended to be elevated in patients with the highest triage level, compared to patients with lower triage levels (ns). In longitudinal analyses, TNFR1 but not TNFR2 was associated with increased short-term mortality, HR adjusted for age, BMI and creatinine 1.43 (95% CI 1.07–1.91), but not in the model also adjusted for CRP, HR 1.29 (95% CI 0.94–1.77). In secondary analysis for quartile 4 versus quartiles 1–3 of TNFR1, corresponding HRs were 2.46 (95% CI 1.27–5.15) and 2.21 (95% CI 1.07–2.56).ConclusionsWe found a trend for the association between circulating TNFR1 levels and short-term mortality in patients with diabetes and acute dyspnea at the ED, possibly suggesting an inflammatory pathway for the association.

Comparison of Four-Level Modification Triage with Five Level Emergency Severity Index (ESI) Triage Based on Level of Accuracy and Time Triase

The triage system currently recommended by the Association of Emergency Physicians (ACEP) and Emergency Nurses Association (ENA) is a five levels triage, Emergency Severity Index (ESI) due to more structured, concise, and clear. Cibabat Hospital used a relatively new triage of four modified levels of the Australian Triage Scale (ATS) which accuracy and time triage have not been evaluated. The purpose of this study was to compare the four level triage of modification of ATS and five levels of ESI triage based on accuracy and time triage. The researcher used a quantitative quasi-experimental design with samples of triage activities totaling 38 in the control group and 38 intervention groups, using accidental sampling techniques. Univariate analysis consisted of frequency distribution for nurse characteristics, time triage and accuracy, bivariate analysis used the Mann-Whitney test. The results showed there were no differences, triage modification of ATS with ESI triage in accuracy (p-0.488), and length of triage (p-0.488) ESI triage accuracy was in the expected triage category (76.3%), under triage (13.2%), and over triage (10.5%). Triage modified ATS, expected triage (73.7%), under triage (18.4%), and over triage (7.9%). ESI triage has more expected and less under triage than ATS modification triage. Under triage caused prolong waiting times, unexpected risks, increases morbidity and mortality. Based on the length of time, ESI triage averaged 167 seconds, triage modification of ATS an average of 183 seconds. ESI flowchrat is easier to understand because is simple, has slight indicators in each category. Conclusion of this study is there is no significant difference in the level of accuracy and duration of triage. However, based on data distribution, ESI triage gives more expected triage decisions, less under triage and 16 seconds faster. Suggestions given to the Cibabat Hospital, can use ESI triage as an alternative triage assessment option because easy to use, structured, simple, and clear.

Accuracy of the Emergency Department Triage System using the Emergency Severity Index for Predicting Patient Outcome; A Single Center Experience.

Objective:To evaluate the accuracy of the five-level triage system using the emergency severity index (ESI) and to determine the compliance of the triage level with patient outcomes. Methods:This was a cross-sectional study which was performed in the emergency department of Imam Reza Hospital of Mashhad during 2017. We included all the adult patients (≥15 years of age) referring to the emergency department. The data were recorded in a questionnaire containing three sections including demographic information, results of triage by ESI and final outcome of the patient. Patients referred to the triage unit were simultaneously triaged by triage nurse and some emergency medicine physicians. The triage was performed by a nurse with an emergency medicine physician (EMP) was considered as a gold standard and the outcome was compared in 24 hours later.Results:Overall, we included 400 patients with a mean age of 46.40 ± 18.52 years among whom there were 211 (52.8%) men and 189 (47.3%) women. Finally, 123 patients were hospitalized, 12 died, 256 were discharged by a physician, and 9 people left the hospital with their own consent. The calculated weight kappa was used to determine the agreement between the observers (nurse triage and physician) at 0.701 so that the agreement between the triage performed by a nurse and an EMP was in an excellent level (p<0.001). There was a significant relationship between the triage levels (determined by physicians) and the outcome of the patient (p<0.001), and the five-level system had a high overlap and significant relation with patient's outcome.Conclusion:The results of the current study revealed that the five-level triage system using the ESI has a high accuracy in triage and estimates the patient outcomes effectively and thus, could be used as an effective system in hospital triage.

'See and Treat' Clinic Service Evaluation at a Tertiary Care Hospital in Abu Dhabi.

ObjectivesWe sought to evaluate the performance provided at a ‘See and Treat’ (ST) clinic at a tertiary hospital emergency department (ED) in Abu Dhabi, UAE, and to assess its impact on ED crowding.MethodsWe conducted a retrospective electronic medical chart review and database analyses. We included patients triaged as triage level 4 (T4) and triage level 5 (T5) as per the Emergency Severity Index treated at ED in the ST clinic and other ED areas, including the off-site Urgent Care Centre (UCC) between 1 June 2016 and 30 June 2017. We analyzed a group of process and outcome measures at our ST clinic and compared them to the same measures in other areas of our ED and the co-located UCC. The process measure analyzed was the door-to-doctor time. In addition, the outcome measures analyzed were the door-to-door time, unplanned return within 72 hours, and feedback from T4 and T5 triaged patients treated at the clinic.ResultsThe number of patients enrolled in the study was 43 109. Of these, 11 329 (26.3%) patients were treated at the ST clinic, 6328 (14.7%) were treated at the UCC, and 25 452 (59.0%) were treated at the main ED. The door-to-doctor time was within 30 minutes for 89.0% of ST clinic patients, and 94.0% of patients experienced a door-to-door time of within two hours; 2.1% of these patients returned within 72 hours. Among these, 78.7% returned for an issue related to their first visit. However, none of the patients were admitted on their return visit. For patients presenting to UCC and other parts of our ED, we recorded a door-to-doctor time of within 30 minutes for 80.5% of patients and a door-to-door time of within two hours for 73.0% of patients. We found the difference in waiting times (i.e., door-to-doctor times between ST clinic patients and the rest of ED) to be statistically significant (p < 0.001, 95% confidence interval (CI): 0.56–0.63). However, on comparing door-to-door times, we found the difference between ST clinic patients and the rest of ED patients was not statistically significant.ConclusionsDoor-to-doctor times were shorter in ST clinics compared to other parts of our ED, but there was no statistically significant difference in door-to-door times when comparing ST clinics to the rest of the ED. ST clinic patients had a lower rate of unplanned return within 72 hours, of which, none required admission on the return attendance. We believe ST clinics have a positive impact on reducing ED crowding but acknowledge they are one of the many plausible solutions attributing to optimized patient flow in the ED.

The Association Between Emergency Department Revisit and Elderly Patients.

Emergency department (ED) revisits may be associated with a higher percentage of adverse events and increased costs. Our hospital is a university affiliation hospital accepted regional referral patients, and located in the region in Taiwan with the highest percentage of elderly people. In this study, we attempted to identify whether old age was a risk factor of ED revisit. Patients who visited the ED from July 2011 to June 2016 were included. Factors associated with revisit were collected from medical information database. A total of 239,405 patients were included in our study, with 13,272 having ED revisits within 72 hours. Chi square and independent t test were applied for univariable factors, and a logistic regression model was used for multivariable analysis. Old age (age ≥ 65 years) was found to be a risk factor for ED revisit (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.09-1.19). Diagnosis, pulse rate, diastolic blood pressure, fever, pain management, paracentesis, triage level, registration category, male gender, discharge status, and major illness may have some effect on ED revisit. In our patients, old age is a risk factor for ED revisit; however, only a weak association was found.

Measuring vital signs in children with fever at the emergency department: an observational study on adherence to the NICE recommendations in Europe

Vital signs can help clinicians identify children at risk of serious illness. The NICE guideline for fever in under-fives recommends a routine measurement of temperature, heart rate, capillary refill and respiratory rate in all febrile children visiting the emergency department (ED). This study aims to evaluate the measurement of paediatric vital signs in European EDs, with specific attention to adherence to this NICE guideline recommendation. In a prospective observational study, we included 4560 febrile children under 16 years from the ED of 28 hospitals in 11 European countries (2014–2016). Hospitals were academic (n = 17), teaching (n = 10) and non-teaching (n = 1) and ranged in annual paediatric ED visits from 2700 to 88,000. Fifty-four percent were male, their median age was 2.4 years (IQR 1.1–4.7). Temperature was measured most frequently (97%), followed by capillary refill (86%), heart rate (73%), saturation (56%) and respiratory rate (51%). In children under five (n = 3505), a complete measurement of the four NICE-recommended vital signs was performed in 48% of patients. Children under 1 year of age, those with an urgent triage level and with respiratory infections had a higher likelihood of undergoing complete measurements. After adjustment for these factors, variability between countries remained.Conclusion: Measuring vital signs in children with fever in the ED occurs with a high degree of practice variation between different European hospitals, and adherence to the NICE recommendation is moderate. Our study is essential as a benchmark for current clinical practice, in order to tailor implementation strategies to different European settings.What is Known:• Vital signs can quickly provide information on disease severity in children in the emergency department (ED), and the NICE guideline for fever in under-fives recommends to routinely measure temperature, heart rate, capillary refill and respiratory rate.• Data regarding measurement of vital signs in routine practice across European EDs is currently unavailable.What is New:• Measurement of vital signs in febrile children is highly variable across European EDs and across patient subgroups, and compliance to the NICE recommendation is <50%.• Children under 1 year of age, those with an urgent triage level and with respiratory infections had a higher likelihood of undergoing complete measurements.

The Impact of a Concierge Medicine Model on Door to Doctor Time and Patient Flow in an Urban Emergency Department.

IntroductionEmergency Department (ED) crowding negatively impacts patient outcomes, patient satisfaction, and patient safety. One solution involves introducing a Concierge Physician (CP) whose sole purpose is to provide a brief initial assessment (BIA) and aid patient navigation through the ED. The goal of this study was to quantify the impact of a CP on patient flow dynamics in an urban ED setting.MethodsWe performed a retrospective observational cohort study in an urban academic ED over a 6-month period. Initially, the CP was present in the treatment area during weekdays; during the last half of the observation period, an additional CP was added to the waiting room on weekends. We identified four major milestones in the ED visit with regards to patient throughput. Adult patients presenting to the ED with a triage level of Urgent (ESI 3) were analyzed for this study. Data were stratified based on the patient’s ultimate disposition (admitted or discharged) and presented as means with predictive analysis.ResultsBetween August 2016 and January 2017, the ED evaluated 42,397 adult patients. Of those, 26,976 (64%) were triage level Urgent (3). Of the level 3 patients, 10,279 (38%) received a BIA from a CP. Patients evaluated by a CP were seen approximately 30 mins faster (40% reduction in Door to Doctor time), but stayed 30 mins longer in the ED on average, because the medical decision-making process took >1 hr longer when the patient was initially evaluated by a CP.ConclusionAdapting a concierge medicine model to rapidly evaluate patients resulted in a dramatically reduced Door to Doctor time, but an increase in overall time spent in the ED. This discrepancy was a direct result of the delay in physician disposition.

Creating a CAR-T Cell Presentation Tool for the Emergency Room

Topic Significance & Study Purpose/Background/Rationale Chimeric antigen receptor T cell (CAR-T cell) therapy has become a promising treatment for children with acute lymphoblastic leukaemia (ALL) and Non-Hodgkin lymphoma (NHL). Cytokine release syndrome (CRS) and Immune effector cell associated neurotoxicity syndrome (ICANS) are well-documented serious side-effects of CAR-T cell therapy, and early recognition, intervention and aggressive supportive therapy is paramount. Tociluzimab is the mainstay of treatment for moderate to severe CRS, with early administration essential. Corticosteroids should be reserved for life-threatening CRS or ICANS as their use may negate CAR-T cell activity. Emergency rooms (ER) are frontline in the assessment, escalation and treatment of CAR-T cell side effects. In establishing our CAR-T cell program, we have established a robust multi-disciplinary education approach and identified key a visual tool for prompt identification of these patients on presenting to the ER. Methods, Intervention, & Analysis Alongside multi-disciplinary training, we have devised a credit card sized tool for parents/carers to present to the ER triage on arrival, creating a visual prompt for their care. The card details that the child has recently received CAR-T cells and outlines the risk of CRS and ICANS. It highlights the location of guidelines on the hospital electronic information system and most importantly alerts ER staff against the administration of corticosteroids, unless previously discussed with the transplant and cellular therapy (TCT) team. The card is orange in color depicting the ‘triage level' of half an hour for medical review. It will be given to all parents/carers once their child has received CAR-T cells. Findings & Interpretation We hope to present preliminary results soon, relating to the ER staff experience, patient's journey and outcomes. Discussion & Implications It is vital that children with CRS and ICANS are triaged efficiently and treated promptly on admission to hospital. We have devised a tool to help expedite their journey through the ER in a safe manner. Alongside electronic medical record alerts, we foresee this tool will assist in the provision of high-quality, targeted therapy to minimize potentially reversible, life-threatening toxicities.

Comparison of penetrating thoracic traumas in patients with gunshot and stab wounds in an emergency department

Objectives: Thoracic trauma is among the most important causes of mortality in emergency departments. In this study of penetrating stab wounds (PSWs) and gunshot wounds (GSWs) admitted to the emergency department with penetrating thoracic trauma cases clinical findings, emergency treatment approaches and survivals were compared with literature information. Methods: One hundred fifty-two patients who applied to Bakırköy Dr. Sadi Konuk Training and Research Hospital Emergency Department with penetrating thoracic trauma on 1 January 2014 and 31 December 2014 were evaluated retrospectively the patients. SPSS 22.0, NY, USA program was used in the analyzes. Results: Patients administered with PSW were 79.6%, with GSW were 20.4%. Patients in the group GSW were admitted to the emergency department with more serious symptoms than patients in the group PSW (Triage level 2, GSW: 87.1%, PSW: 62.8% and Triage level 3, GSW: 12.9% vs. PSW: 37.2%), (p = 0.010). Hemothorax (25.8%) in PSW patients and pneumothorax (40.5%) in GSW patients was detected more frequently. Surgical treatment was performed in 14.9% of patients with PSW, tube thoracostomy was performed in 24%, and 62.82% were treated with conservative treatment. Surgical treatment was performed in 35.5% of GSW patients and tube thoracostomy was performed in 29%, and 48.4% were treated with conservative treatment (p &amp;gt; 0.05). Conclusion: Despite the lower incidence of GSW than PSW in emergency departments, GSW require more surgical intervention and have a higher mortality rate.

Who is Next: Patient Prioritization Under Emergency Department Blocking

Upon arrival at emergency departments (EDs), patients are classified into different triage levels indicating their urgency. Using data from a large hospital in Canada, we find that within the same triage level, the average waiting time (time from triage to initial assessment by a physician) of patients who are discharged is shorter than that of patients who are admitted for middle-to-low acuity patients, suggesting that the order in which patients are served deviates from FCFS (first-come-first-served), and to a certain extent, discharged patients are prioritized over admitted patients. This observation is intriguing as among patients of the same triage level, admitted patients--who need further care in the hospital--should be deemed no less urgent than discharged patients who only need treatment at the ED. To understand how ED decision makers choose the next patient for treatment, we estimate a discrete-choice model and find that ED decision makers apply urgency-specific delay-dependent prioritization. Moreover, we find that when the ED blocking level is sufficiently low, admitted patients are prioritized over discharged patients for high acuity patients, whereas disposition does not affect the prioritization of middle-to-low acuity patients. When the ED blocking level becomes sufficiently high, decision makers start to prioritize discharged patients in an effort to avoid further blocking the ED. We then analyze a stylized model to explain the rationale behind the change in decision makers' prioritization behavior as the ED blocking level increases. Using a simulation study, we demonstrate how policies inspired by our findings improve ED operations by reducing the average patient waiting time and length of stay, resulting in significant cost savings for hospitals. We also show how to leverage our findings to improve the accuracy of ED waiting time predictions. By testing and highlighting the central role of decision makers' patient prioritization behavior, this paper advances our understanding of ED operations and patient flow.

Two teams, one mission: A study using EMS units in hospital triage during active-shooter and other mass-casualty events.

Recent mass-casualty events have exposed errors with common assumptions about response proc-esses, notably triage and transport of patients. Response planners generally assume that the majority of patients from a mass-casualty event will have received some level of field triage and transport from the scene to the hospital will have been coordinated through on-scene incident command. When this is not the case, emergency response at the hospital is hampered as staff must be pulled to handle the influx of untriaged patients. Determine whether the use of emergency medical service (EMS) field resources in hospital triage could enhance the overall response to active-shooter and other mass-casualty events. A proof of concept study was planned in conjunction with a regularly scheduled mass-casualty hospital ex-ercise conducted by an urban level II trauma center in Utah. This was a cross-over study with triage initially performed by hospital staff, and at the midpoint of the exercise, triage was transferred to EMS field units. General performance was judged by exercise planners with limited additional data collection. EMS crews at the hospital significantly enhanced the efficiency and efficacy of the triage operation in both qualitative and quantitative assessment. Hospital planners deemed the proof of concept exercise a success and are now experimenting with implementation of this alternate approach to triage. However, much additional work remains to fully implement this change in processes.

Factors Associated with Triage Modifications Using Vital Signs in Pediatric Triage: a Nationwide Cross-Sectional Study in Korea.

BackgroundPrevious studies on inter-rater reliability of pediatric triage systems have compared triage levels classified by two or more triage providers using the same information about individual patients. This overlooks the fact that the evaluator can decide whether or not to use the information provided. The authors therefore aimed to analyze the differences in the use of vital signs for triage modification in pediatric triage.MethodsThis was an observational cross-sectional study of national registry data collected in real time from all emergency medical services beyond the local emergency medical centers (EMCs) throughout Korea. Data from patients under the age of 15 who visited EMC nationwide from January 2016 to December 2016 were analyzed. Depending on whether triage modifications were made using respiratory rate or heart rate beyond the normal range by age during the pediatric triage process, they were divided into down-triage and non-down-triage groups. The proportions in the down-triage group were analyzed according to the triage provider's profession, mental status, arrival mode, presence of trauma, and the EMC class.ResultsDuring the study period, 1,385,579 patients' data were analyzed. Of these, 981,281 patients were eligible for triage modification. The differences in down-triage proportions according to the profession of the triage provider (resident, 50.5%; paramedics, 47.7%; specialist, 44.9%; nurses, 44.2%) was statistically significant (P < 0.001). The triage provider's professional down-triage proportion according to the medical condition of the patients showed statistically significant differences except for the unresponsive mental state (P = 0.502) and the case of air transport (P = 0.468).ConclusionDown-triage proportion due to abnormal heart rates and respiratory rates was significantly different according to the triage provider's condition. The existing concept of inter-rater reliability of the pediatric triage system needs to be reconsidered.

The first national data of Turkish pre-hospital emergency care for children: Epidemiology, clinical characteristics, and outcomes

Background and Objectives: The emergency medical service system is designed to ensure rapid identification and transport of patients from the field to emergency departments. This study aims to examine pediatric patients’ clinical characteristics and reasons for ambulance use in Turkey. Life-saving interventions and non-life-saving interventions performed during transport and patients’ outcomes following transport were also investigated. Methods: This is a prospective-multicentric study conducted at four metropolitan cities and nine tertiary pediatric emergency departments. This survey-based study evaluated all children brought by ambulance to emergency departments. Patient demographics, clinical features, triage levels, procedures performed in the ambulance or emergency department, and final outcomes were sought. Results: A total of 2094 patients were transported during the study period. Only a minority of ambulances were physician staffed (16.5%), and 72% of the patients were delivered to pediatric emergency departments without notification calls. Although notification calls were more likely given for particularly critically ill children, for non-urgent conditions transfer calls were less common (60.8% vs 23.5%, respectively; p &lt; 0.001). A majority of transports were performed for trauma patients (20.5%), neurological issues (20%), and toxicological emergencies (13.8%). While parents prefer using the ambulances for medical emergencies, physicians prefer it for mainly traumatic and toxicological emergencies. In total, 65% of the patients received at least one intervention, and 18 patients needed immediate life-saving interventions (intubation, cardiopulmonary resuscitation, etc.) but they did not receive it. Mortality occurred in nine patients. If the health care providers were paramedics, they were more likely avoided by performing any intervention in critically ill children ( p &lt; 0.001). A majority of the procedures performed in children were older than 12 months ( p &lt; 0.001). Conclusion: This study presents comprehensive epidemiological and outcome data for pediatric patients transported by the national emergency medical service system in Turkey. Non-urgent calls were more likely made by parents, physicians avoided making NCs, and paramedics also avoided performing any intervention when they were transporting children.