Triage Level Research Articles

Validity of the Manchester Triage System in emergency patients receiving life‐saving intervention or acute medical treatment—A prospective observational study in the emergency department

The spectrum of cases seen by emergency departments ranges from minor illnesses or injuries to complex diseases with high mortality. Some patients require life-saving interventions (LSIs) or therapeutic treatment for an acute illness to prevent an expected imminent life-threatening condition immediately upon arrival. No published study has evaluated the validity of the Manchester Triage System (MTS) in the context of immediate LSI or acute emergency treatment (AET). The definition of LSI was based on a literature search. AET was defined by an expert panel based on current emergency guidelines and diagnostic guideline recommendations. In a 4-month observation period, an independent external observer documented all executed LSIs or AETs using a checklist. Sensitivity, negative predictive value, likelihood ratio negative (LR-), and accuracy of MTS triage level for the identification of patients receiving an LSI or AET were calculated. In 1762 patients, 40 (2.3%) LSIs and 89 (5.1%) AETs were observed. In the LSI group, sensitivity of MTS was 75.0%, negative predictive value (NPV) was 99.2% (95% CI: 98.7%-99.6%), LR- was 0.303 (95% CI: 0.189-0.487) and accuracy (ACC) was 98.5% (95% CI: 97.8%-98.9%). In the AET group, sensitivity was 82.0%, NPV was 98.9% (95% CI: 98.1%-99.3%), LR- was 0.206 (95% CI: 0.132-0.322), and ACC was 86.5% (95% CI: 84.9%-88.1%). The MTS is a valid instrument for a first assessment of emergency patients in critical condition upon arrival.

Comparing resource use between paediatric emergency department visits by triage level

ObjectiveThe majority of paediatric ED visits result in discharge but little is known about what ED resources are deployed for these visits. The goal of this study was to understand...

Significant changes in emergency department length of stay and case mix over eight years at a large Swedish University Hospital

ObjectiveDescribe the longitudinal development of crowding and patient/emergency department (ED) characteristics at a Swedish University Hospital. MethodsA retrospective longitudinal registry study based on all ED visits with adult patients during 2009–2016 (N = 1,063,806). Patient characteristics and measures of ED crowding (ED occupancy ratio, length-of-stay [LOS], patients/clinician’s ratios) were extracted from the hospital’s electronic health record. Non-parametric analyses were conducted. ResultsThe proportion of unstable patients (triage level 1–2) increased while the proportion of admitted patients decreased. All crowding variables were stable, except for LOS, which increased by 9 min/visit/year (95% CI: 8.8–9.1). LOS for visits by patients ≥ 80 years increased more compared to those 18–79 (248 min vs. 190 min, p < 0.001). Unstable patients increased their median LOS compared to stable patients (triage level 3–5). LOS for discharged patients increased with an average of 7.7 min/year (95% CI: 7.5–7.9) compared to 15.5 min/year (95% CI: 15.2–15.8) for those being admitted. ConclusionFewer admissions, despite an increase of unstable patients, is likely related to lack of in-hospital beds and contributes to ED crowding. The increase in median ED LOS, especially for patients in the subgroups unstable, ≥80 years and admitted to in-hospital care reflects this problem.

Effect of age on waiting time of emergency patients: a retrospective analysis of 219 299 patients in consecutive 2 years

To evaluate whether patients aged over 70 years old is an independent predictor for prolonging the waiting time, and to know whether the population can be prioritized in the emergency grading system. A retrospective analysis was conducted. All the clinical data of adult visitors to the emergency department of the Third Affiliated Hospital of Sun Yat-sen University from January 1st in 2016 to December 31st in 2017 were collected. All the patients received four emergency first aid triages and treated according to the emergency classification results. The relevant data of selected patients were retrieved from the hospital information system (HIS) including gender, age, triage level, triage department, outpatient service and initial diagnosis time. According to the conclusion of pre-phase analysis that the patients over 65 years old was not associated with waiting time, all subjects were divided into ≥ 70 years old group and < 70 years old group for further analysis. The waiting time was defined as the difference in registration time and the initial diagnosis time, and the patients were divided into two groups according to whether it exceeded the target waiting time (TWT). TWT was considered as follows according to each emergency triage level: level I instantly, level II 10 minutes, level III 30 minutes, level IV 60 minutes (subacute patients) or 2-4 hours (non-urgent patients). The multivariable Logistic regression analysis was conducted to determine whether the factor that aged over 70 years old was an independent predictor for prolonging waiting time over TWT. There were 272 989 adult visits recorded totally, of which obstetrics and gynecology department visits, incomplete personnel information, invalid diagnosis (or no diagnosis), triage level I, abnormal waiting time (the waiting time exceeded 99% of the average waiting time of all samples) records were excluded. Finally, 219 299 emergency patients were enrolled, with 102 218 male and 117 081 female, which showed an average age of (35.86±15.81) years, 208 082 patients (94.9%) in < 70 years old group, and 11 217 (5.1%) in ≥ 70 years old group. Totally 191 588 patients (87.4%) were diagnosed within the TWT, and the number was 86.5% (9 701/11 217) in the ≥ 70 years old group. Multivariate Logistic regression analysis indicated that age under 70 years old was independently associated with an exceeded TWT [adjusted odds ratio (OR) = 1.106, 95% confidence interval (95%CI) = 1.041-1.176, P = 0.001]. Meanwhile, visits during the peak period or low triage level was also a risk factor of exceeded TWT. According to the Logistic regression analysis of different departments and removing other factors, in the emergency internal medicine with the most elderly patients, the probability of exceeded TWT in ≥ 70 years old group was lessened (adjusted OR = 1.203, 95%CI = 1.121-1.291, P < 0.001). In the emergency pre-grading system, the elderly aged (≥ 70 years old) was more likely to see a doctor in TWT than those under 70 years old, so they were easy to get priority treatment.

Introduction of a mass burn casualty triage system in a hospital during a powder explosion disaster: a retrospective cohort study

BackgroundThe triage system used during an actual mass burn casualty (MBC) incident is a major focus of concern. This study introduces a MBC triage system that was used by a burn center during an actual MBC incident following a powder explosion in New Taipei City, Taiwan.MethodsThis study retrospectively analyzed data from patients who were sent to the study hospital during a MBC incident. The patient list was retrieved from a national online management system. A MBC triage system was developed at the study hospital using the following modifiers: consciousness, breathing, and burn size. Medical records were retrieved from electronic records for analysis. Patient outcomes consisted of emergency department (ED) disposition and intervention.ResultsThe patient population was predominantly female (56.3%), with an average age of 24.9 years. Mean burn sizes relative to the TBSA of triage level I, II, and III patients were 57.9%, 40.5%, and 8.7%, respectively. ICU length of stay differed markedly according to triage level (mean days for levels I vs II vs III: 57.9 vs 39.9 vs 2.5 days; p < 0.001). Triage system levels I and II indicate ICU admission with a sensitivity of 93.9% (95%CI 80.4–98.3%) and a specificity of 86.7% (62.1–96.3%).Overall, 3 (6.3%) patients were under-triaged. Two (4.2%) patients were over-triaged. Sixteen (48.5%) and 21 (63.6%) patients of triage levels I and II received endotracheal intubation and central venous catheterization, respectively. Sorting of the study population with simple triage and rapid treatment (START) showed great sensitivity (100.0%) but poor specificity (53.3%). The Taiwan Triage and Acuity Scale (TTAS) presented 87.9% sensitivity and 93.9% specificity.ConclusionsThe current MBC triage algorithm served as a good indicator of ED disposition but might have raised excessive immediate attention and had the potential to exhaust the available resources. These findings add to our knowledge of the MBC triage system and should help future researchers in adjusting the triage criteria to fit actual disasters.

Increased Urgent Care Center Visits by Southeast European Migrants: A Retrospective, Controlled Trial from Switzerland.

We investigated whether immigrants from Southeast Europe (SE) and Swiss patients have different reasons for visiting the emergency department (ED). Our retrospective data analysis for the years 2013–2017 describes the pattern of ED consultations for immigrants from SE living in Switzerland (Canton Bern), in comparison with Swiss nationals, with a focus on type of referral and reason for admission. A total of 153,320 Swiss citizens and 12,852 immigrants from SE were included in the study. The mean age was 51.30 (SD = 21.13) years for the Swiss patients and 39.70 (SD = 15.87) years for the SE patients. For some countries of origin (Albania, Bosnia and Herzegovina, and Turkey), there were highly statistically significant differences in sex distribution, with a predominance of males. SE immigrants had a greater proportion of patients in the lower triage level (level 3: SE: 67.3% vs. Swiss: 56.0%) and a greater proportion of patients in the high triage level than the Swiss population (level 1: SE: 3.4% vs. Swiss: 8.8%). SE patients of working age (16–65 years) were six times more often admitted by ambulance than older (≥65 years) SE patients, whereas this ratio was similar in the Swiss population. In both groups, the fast track service was primarily used for patients of working age (<65) and more than three times more often in the SE than the Swiss group (SE: 39.1%, Swiss: 12.6%). We identified some indications for access to primary care in emergency departments for immigrants and highlighted the need for attention to the role of organizational characteristics of primary health care in Switzerland. We highlighted the need for professional support to improve the quality of healthcare for immigrants. In the future, we will need more primary care services and general practitioners with a migrant background.

Determining Potentially Avoidable Emergency Medical Services (EMS) Transports: A Population Level Study Using Linked Administrative Data in Alberta Health Services (AHS)

IntroductionTraditionally Emergency Medical Services (EMS) transports patients to Emergency Departments (EDs). However, some patients might be appropriately managed in alternative settings outside the ED. A number of non-traditional EMS programs have evolved in Alberta, in an attempt to provide quality care through a community-based care model.&#x0D; Objectives and ApproachThe project aimed to identify and quantify potentially avoidable EMS transports to EDs in Alberta.&#x0D; We identified 911 responses by ground ambulance in Alberta between September 1, 2017 and December 31, 2017. Patients 18 years and over transported to EDs were linked to Alberta Provincial Registry for more accurate demographic Information, and linked to Long Term Care (LTC) and ED data to capture patient characteristics and frequency of potentially avoidable EMS transports to EDs, defined as the Canadian Triage and Acuity Scale (CTAS) Level IV and Level V in EDs not requiring inpatient admission.&#x0D; ResultsWe identified 72,182 transports to EDs, of which 1 in 4 patients were rural residents. After excluding individuals&lt;18 years and non-Alberta residents, we were able to match 58,137 of the 60,020 EMS transports to EDs (96.8%). Overall, 7,697 (13%) were triaged as less urgent with no hospital admission. Patients 65 years and over accounted for almost half (49%) of the transports in this cohort, 6% of which were for LTC clients. Percentage of potentially avoidable transports in LTC clients were similar to seniors living in the community (12%). Geographic visualization at the provincial level indicated variation across the province. In general, rural residents were more likely than urban residents to be transported to EDs with less urgent conditions (18% vs 12%).&#x0D; Conclusion/ImplicationsThis is the first analysis exploring potentially avoidable EMS transports to EDs in Alberta, Canada, where a comprehensive, single source of EMS system data is currently available. The project suggests opportunities for future EMS research and policies focusing on enhancing community–based care.

Validity of the Pediatric Canadian Triage Acuity Scale in a tertiary children's hospital in Israel.

In 2015, the Israeli Ministry of Health issued national guidelines demanding the use of a five-level triage system in pediatric emergency departments (EDs). The present study aimed to evaluate the validity of the Pediatric Canadian Triage Acuity Scale (PedCTAS) in the ED of a tertiary children's hospital in Israel. A retrospective cohort study of all patients admitted between January 2011 and December 2015 was carried out. The proportion of hospitalization was the primary outcome measure. The secondary outcomes were proportion of admissions to the ICU, proportions of patients who left without being seen (LWBS), and length of stay (LOS) in the ED. A total of 83 609 patients were included in our analysis. Triage levels 1-5 included 533 (0.6%), 4428 (5.3%), 46 461 (55.6%), 28 510 (34.1%), and 3677 (4.4%) patients, respectively. Hospitalization proportions were 70, 51, 28, 15, and 12% for triage levels 1, 2, 3, 4, and 5, respectively. Admission proportions to ICU were 24.2, 3.05, 0.24, 0.05, and 0.05% for PedCTAS levels 1, 2, 3, 4, and 5, respectively. The proportions of LWBS were 0.001, 0.002, and 0.005% for triage levels 3, 4, and 5, respectively. LOS was shorter as the triage level increased from 2 to 5. Triage level was predictive of hospitalization, admission to the ICU, and proportions of LWBS and LOS in the ED. The findings suggest validity of the PedCTAS in this cohort. This is the first report of the performance of a triage tool in an Israeli ED.

Round-off decision-making: Why do triage nurses assign STEMI patients with an average priority?

Patients with suspected ST elevation myocardial infarction should be classified with a high-priority triage level in the Emergency Department. Accurate triage can reduce mortality and morbidity in ST elevation myocardial infarction patients. Yet, half of these patients were given a low-priority score, especially the average classification (P3 on a P1–P5 scale). AimTo identify and clarify significant factors in the triage process that result in P3 assignment for patients with ST Elevation Myocardial Infraction diagnosis. MethodsA retrospective-archive study was conducted at a tertiary hospital from January 2015 to November 2017. We collected and measured patients’ characteristics, Emergency Department setting variables, and hospitalization characteristics. Data files were extracted from the electronic database (n = 140). ResultsThe results show several key factors that affect the decision to assign P3 in the triage process. Analysis of patients’ sociodemographic characteristics show that being female (OR = 1.96, P = .05) or having Arab ethnicity (OR = 2.19, P = .01) is significant to P3 assignment. Number of cardiac events (P = .02) is the only noteworthy cardiologic comorbidity of all that were reviewed.A connection was observed between a patient being classified as average urgency and poor treatment outcomes, namely for the variables time to physician, total time in the Emergency Department, door-to-balloon time, and in-hospital mortality. ConclusionAverage classification demonstrates the extreme risk involved in the triage process. Our research provides considerable data to identify factors that affect the decision to classify patients as P3.

Differences in triage category, priority level and hospitalization rate between young-old and old-old patients visiting the emergency department

BackgroundEmergency Department (ED) are challenged by the increasing number of visits made by the heterogeneous population of elderly persons. This study aims to 1) compare chief complaints (triage categories) and level of priority; 2) to investigate their association with hospitalization after an ED visit; 3) to explore factors explaining the difference in hospitalization rates among community-dwelling older adults aged 65–84 vs 85+ years.MethodsAll ED visits of patients age 65 and over that occurred between 2005 and 2010 to the University of Lausanne Medical Center were analyzed. Associations of hospitalization with triage categories and level of priority using regressions were compared between the two age groups. Blinder-Oaxaca decomposition was performed to explore how much age-related differences in prevalence of priority level and triage categories contributed to predicted difference in hospitalization rates across the two age groups.ResultsAmong 39′178 ED visits, 8′812 (22.5%) occurred in 85+ patients. This group had fewer high priority and more low priority conditions than the younger group. Older patients were more frequently triaged in “Trauma” (20.9 vs 15.0%) and “Home care impossible” (10.1% vs 4.2%) categories, and were more frequently hospitalized after their ED visit (69.1% vs 58.5%). Differences in prevalence of triage categories between the two age groups explained a quarter (26%) of the total age-related difference in hospitalization rates, whereas priority level did not play a role.ConclusionsPrevalence of priority level and in triage categories differed across the two age groups but only triage categories contributed moderately to explaining the age-related difference in hospitalization rates after the ED visit. Indeed, most of this difference remained unexplained, suggesting that age itself, besides other unmeasured factors, may play a role in explaining the higher hospitalization rate in patients aged 85+ years.

Management of cardiogenic shock complicating myocardial infarction.

Up to 10% of acute coronary syndromes are complicated by cardiogenic shock (CS) with contemporary mortality rates of 40-50%. The extent of ischemic myocardium has a profound impact on the initial, in-hospital, and post-discharge management and prognosis in this patient population. Individualized patient risk assessment plays an important role in determining appropriate revascularization, drug treatment with inotropes and vasopressors, mechanical circulatory support, intensive care support of other organ systems, hospital level of care triage, and allocation of clinical resources. This review will outline the underlying causes and diagnostic criteria, pathophysiology, and treatment of CS complicating acute coronary syndromes with a focus on (a) potential therapeutic issues from the perspective an interventional cardiologist, an emergency physician, and an intensive care physician, (b) the type of revascularization, and (c) new therapeutic advancements in pharmacologic and mechanical percutaneous circulatory support.

Quality of the Triage of Children With Anaphylaxis at the Emergency Department.

Early recognition of symptoms is essential in anaphylaxis management. The Canadian Paediatric Emergency Triage and Acuity Scale prioritizes anaphylaxis to level I or II (resuscitation or emergency). We analyzed the accuracy of pediatric anaphylaxis triage. This was a retrospective review of the triage charts (adaptation of the Canadian Paediatric Emergency Triage and Acuity Scale) of 137 children attended for anaphylaxis at our pediatric emergency department. Per triages' accuracy, charts were divided into TR1 (levels I-II) and TR2 (levels III-V), comparing demographics, initial triage level given by initial assessment (Paediatric Assessment Triangle), vital signs, observations recorded by the staff, and waiting times for physician. Forty-six (33.3%) were triaged correctly (TR1 group), and 91 (66.7%) were not. Median ages were similar (TR1: 5 years [interquartile range, 13.1 years] vs TR2: 4.5 years [interquartile range, 14.5 years]; P = 0.837). Initial triage level 5 was given by Paediatric Assessment Triangle to 69.5% of TR1 and 83% of TR2 cases (P = 0.001; likelihood ratio for TR2: 1.985 [95% confidence interval, 1.11-3.49]). Vital signs were normal in 71.7% of TR1 and 94.5% of TR2 patients (P < 0.001; likelihood ratio for TR2: 2.602 [95% confidence interval, 1.22-5.52]). Symptoms suggestive of anaphylaxis (mention of 2 different organs) were recorded in 45.6% of TR1 and 48.3% of TR2 charts (P = 0.08). Median waiting times were 3 minutes (interquartile range, 26 minutes) and 11 minutes (interquartile range, 111 minutes) for TR1 and TR2, respectively (P = 0.001). Current triage, based on severity perception, missed most of the cases. Anaphylaxis-defining symptoms were overlooked. Inaccurate triage delayed medical attention. Improving measures, such as emphasizing symptom recognition and defining anaphylaxis risk discriminators, is mandatory to improve their identification.

Frequency of Miss Triage Using Emergency Severity Index and Shock Index in Patients with Abdominal Trauma

Background: Triage of trauma patients is particularly important. Correct triage can reduce the rate of mortality and prevent disability in trauma patients. Objectives: The current study aimed at comparing the frequency of miss triage using the two methods namely emergency severity index (ESI) and shock index, in patients with abdominal trauma. Methods: Trauma patients referring to Shahid Rajaee hospital, were included as the study population. A census survey was conducted for three months. Data were collected by a demographic questionnaire, a five-level triage system checklist, and triage form based on the shock index. Content validity of the questionnaire was confirmed by experts and Patients were simultaneously evaluated by both ESI and shock index methods. The triage level in each method was compared with the triage level approved by an emergency clinician. Data were analyzed with SPSS version 18. Results: Based on ESI, 6.3% of patients were under-triaged and 2.7% over-triaged; but based on the shock index, 36.2% of the patients were under-triaged and 19.2% over-triaged. There was a positive correlation between each of the two methods and the final score of triage. Moreover, the correlation coefficient of the final score in the five-level triage system was higher than that of the shock index (r = 0.834 vs. r = 0.162). Conclusions: According to the results, the shock index can be used as an auxiliary tool in the triage of traumatic patients in emergency departments.

LO67: A variation on Triage Liaison Physicians (TLP): a comparative analysis of the Emergency Department Disposition and Care Consultant (EDC) concept

Introduction: Despite evidence that triage liaison physicians (TLP) effectively reduce emergency department (ED) overcrowding, support for these interventions is patchy. The aim of this study was to evaluate the implementation of a TLP-like ED Disposition and Care Consultant (EDC) shift at an academic tertiary care ED. Methods: A 24-week pilot project was conducted 11/16-04/17. Physicians worked 8- hour day (07-15:00) and/or evening (15:00-23:00) EDC shifts and performed immediate triage and patient care when needed, assisted triage RNs, answered all incoming calls, and managed administrative matters. Due to their voluntary nature, not all shifts were filled. This study compared active (EDC) and control (C) shifts on the following ED metrics: length of stay (LOS), proportions of patients who left without being seen (LWBS), and safety (return visits to ED). Descriptive (median and interquartile range {IQR} and proportions) and simple (Wilcoxson-Mann-Whitney, chi-square, z-proportion) tests are presented for continuous and dichotomous outcomes, respectively. Multiple linear regression identified factors associated with LOS. Results: Of 112 possible EDC shifts, 58 (52%) were filled involving 4289 patients and compared to 276 C shifts involving 21,358 patients. ED volume, patient age (49; IQR: 31, 66), mode of arrival (~30% EMS), triage levels (~51% level 3), and complaints were similar between the groups. Overall, the EDC group reduced LWBS by 16% (8.7% vs. 10.4%; p=0.001), ED LOS for discharged patients by 30 minutes (5.5 vs. 6.0 hours; p&lt;0.001), and ED LOS for admitted patients by 42 minutes (9.7 vs. 10.4 hours; p=0.02). The EDC increased the proportion discharged &lt;4 hours by 28% (20.1 vs. 15.7%; p&lt;0.001) and increased the proportion admitted &lt;8 hours by 17% (8.2% vs. 9.6%, p=0.002). ED relapses &lt;72 hours were similar (9.3% vs. 8.9%; p=0.4); however, admissions were higher in the EDC shifts (25.3% vs. 23.8%; p=0.04). In addition to EDC coverage status, LOS was influenced by triage level (1.7%, p&lt;0.001), disposition (19.6%, p&lt;0.001), and age (4.8%, p&lt;0.001). Conclusion: Our results indicate that an EDC shift, while unpopular with many physicians, provides valuable services to an overcrowded ED and that the implementation of this type of shift could reduce LOS and LWBS statistics in a tertiary care institution. Additional evaluations to examine this and other front-end interventions in other ED centers are indicated.

LO02: Characteristics and predictors of pediatric emergency department use in Manitoba: a population based study

Introduction: Within Manitoba, little is known about the current state of pediatric emergency department (ED) use or the state of provincial data collection. This study sought to gain a baseline understanding of pediatric ED use in Manitoba, including child demographics, visit characteristics, variation across the province, drivers of ED use, and data completeness. Methods: A retrospective cohort study was conducted using administrative data from the Manitoba Centre for Health Policy, and included all children aged 0-17 who presented to a Manitoba ED between 2011/12 and 2015/16, as identified from the Emergency Department Information System (EDIS), the National Ambulatory Care Reporting System (NACRS) and physician billing claims. Frequency of use was defined as single, intermediate (2-6 visits) and frequent (7+) and regional trends in child characteristics, ED use, acuity, presenting complaints, and discharge dispositions were observed. Ordinal logistic regression will be used to identify predictors of ED use. Results: Overall, we were able to capture 250,620 ED visits made by 172,306 children; data sources and completeness varied by year. Provincially, children under 5 years of age were the most frequent users of the ED, and use &lt;1 year of age was highest in the North. We observed higher use among low-income children, particularly in rural mid and north, and few differences by sex. By year, the majority of children made single-use of the ED (64.48%), while fewer were classified as intermediate (34.40%) or frequent users (1.11%). Overall, the top presenting complaints were for fever (10.27%), limb complaint/trauma (7.48%), abdominal pain (5.75%), nausea and/or vomiting (4.53%) and shortness of breath (3.68%), with variation by triage level. In rural but not urban areas, mental health assessments were a top presenting complaint and primary reason for transfer to larger centres. Results of predictors of ED use are pending. Conclusion: Results from this study will provide important information about the predictors and variation of ED use by region and top causes for visit, enabling us to better tailor knowledge mobilization efforts and tool development to the local context. Identified gaps in data collection are important to address to advance our knowledge and delivery of pediatric emergency care at the provincial level.

Leaving the emergency department without complete care: disparities in American Indian children

BackgroundChildren who leave the emergency department (ED) without complete evaluation or care (LWCET) have poorer outcomes in general. Previous studies have found that American Indian (AI) children have higher rates of LWCET than other racial or ethnic groups. Therefore, this study aims to examine LWCET in AI children by exploring differences by ED location and utilization patterns.MethodsThis is a retrospective cohort study of five EDs in the upper Midwest between June 2011 and May 2012. We included all visits by children aged 0–17 who identified as African American (AA), AI or White. Logistic regression was used to determine differences in LWCET by race and ED location controlling for other possible confounding factors including sex, age, insurance type, triage level, distance from ED, timing of visit, and ED activity level.ResultsLWCET occurred in 1.73% of 68,461 visits made by 47,228 children. The multivariate model revealed that AIs were more likely to LWCET compared to White children (Odds Ratio (OR) = 1.62, 95% Confidence Interval (CI) = 1.30–2.03). There was no significant difference in LWCET between AA and White children. Other factors significantly associated with LWCET included triage level, distance from the ED, timing of visit, and ED activity level.ConclusionOur results show that AI children have higher rates of LWCET compared to White children; this association is different from other racial minority groups. There are likely complex factors affecting LWCET in AI children throughout the upper Midwest, which necessitates further exploration.

Outcome-Based Validity and Reliability Assessment of Raters Regarding the Admission Triage Level in the Emergency Department: a Cross-Sectional Study.

Introduction:Emergency department (ED) is usually the first line of healthcare supply to patients in non-urgent to critical situations and, if necessary, provides hospital admission. A dynamic system to evaluate patients and allocate priorities is necessary. Such a structure that facilitates patients’ flow in the ED is termed triage.Objective:This study was conducted to investigate the validity and reliability of implementation of Emergency Severity Index (ESI) system version 4 by triage nurses in an overcrowded referral hospital with more than 80000 patient admissions per year and an average emergency department occupancy rate of more than 80%. Method:This prospective cross-sectional study was conducted in a tertiary care teaching hospital and trauma center with an emergency medicine residency program. Seven participating expert nurses were asked to assess the ESI level of patients in 30 written scenarios twice within a three-week interval to evaluate the inter-rater and intra-rater reliability. Patients were randomly selected to participate in the study, and the triage level assigned by the nurses was compared with that by the emergency physicians. Finally, based on the patients’ charts, an expert panel evaluated the validity of the triage level.Results:During the study period, 527 patients with mean age of 54 ± 7 years, including 253 (48%) women and 274 (52%) men, were assessed by seven trained triage nurses. The degree of retrograde agreement between the collaborated expert panel’s evaluation and the actual triage scales by the nurses and physicians for all 5 levels was excellent, with the Cohen’s weighted kappa being 0.966 (CI 0.985–0.946, p < 0.001) and 0.813 (CI 0.856–0.769, p<0.001), respectively. The intra-rater reliability was 0.94 (p < 0.0001), and the inter-rater reliability for all the nurses was in perfect agreement with the test result (Cohen’s weighted kappa were as follows: 0.919, 0.956, 0.911, 0.955, 0.860, 0.956, and 0.868; p < 0.001).Conclusion:The study findings showed that there was perfect reliability and, overall, almost perfect validity for the triage performed by the studied nurses.

Prehospital triage of patients diagnosed with perforated peptic ulcer or peptic ulcer bleeding: an observational study of patients calling 1-1-2

BackgroundTriage systems are used in emergency medical services to systematically prioritize prehospital resources according to individual patient conditions. Previous studies have shown cases of preventable deaths in emergency medical services even when triage systems are used, indicating a potential undertriage among some conditions. The aim of this study was to investigate the triage level among patients diagnosed with perforated peptic ulcer (PPU) or peptic ulcer bleeding (PUB).MethodsIn a three-year period in Central Denmark Region, all patients hospitalized within 24 h after a 1-1-2 emergency call and who subsequently received either a PPU or a PUB (hereinafter combined and referred to as PPU/PUB) or a First Hour Quintet (FHQ: respiratory failure, stroke, trauma, cardiac chest pain, and cardiac arrest) diagnosis were investigated. A modified Poisson regression was used to estimate the relative risk of receiving the highest and lowest prehospital response level. Also, a linear regression analysis was used to estimate the relative risk of 30-day mortality.ResultsOf 8658 evaluated patients, 263 were diagnosed with PPU/PUB. After adjusting for relevant confounding variables, patients diagnosed with PPU/PUB were less likely to receive ambulance transportation compared to patients diagnosed with stroke, RR = 1.41 (CI: 1.28–1.56); trauma, RR = 1.28 (CI: 1.15–1.42); cardiac chest pain, RR = 1.47 (CI: 1.33–1.62); and cardiac arrest, RR = 1.44 (CI: 1.31–1.42). Among patients diagnosed with PPU/PUB, 6.5% (CI: 3.3–9.7) did not receive ambulance transportation. The proportion of patients not receiving ambulance transportation was higher among patients diagnosed with PPU/PUB compared to patients diagnosed with an FHQ diagnosis. The 30-day mortality rate among patients diagnosed with PPU/PUB was 7.8% (CI: 4.2–11.1). This was lower than the 30-day mortality rate among patients diagnosed with respiratory failure (P = 0.010), stroke (P = 0.001), and cardiac arrest (P < 0.001), but comparable to the 30-day mortality among patients diagnosed with cardiac chest pain (P = 0.080) and trauma (P = 0.281).ConclusionAmong patients calling 1-1-2, fewer patients diagnosed with PPU/PUB received ambulance transportation than patients diagnosed with FHQ diagnoses, despite a high mortality among patients diagnosed with PPU/PUB.

The Singapore Paediatric Triage Scale Validation Study

This study aimed to determine the usefulness and validity of the triaging scale used in our emergency department (ED) by analysing its association with surrogate clinical outcome measures of severity consisting of hospitalisation rate, intensive care unit (ICU) admission, length of ED stay, predictive value for admission and length of hospitalisation. A retrospective observational study was conducted of the performance markers of the Singapore Paediatric Triage Scale (SPTS) to identify children who needed immediate and greater care. All children triaged and attended to at the paediatric ED at KK Women's and Children's Hospital, Singapore, from 1 January 2014 to 31 December 2014 were included. Data was retrieved from the Online Paediatric Emergency Care system, which is used for patients' care from initial triaging to final disposition. Among 172,933 ED attendances, acuity levels 1, 2 plus, 2 and 3 were seen in 2.3%, 26.4%, 13.5% and 57.8% of patients, respectively. For admissions, triage acuity level 1 had a strong positive predictive value (79.5%), while triage acuity level 3 had a strong negative predictive value (93.7%). Fewer patients with triage acuity level 3 (6.3%) were admitted as compared to those with triage acuity level 1 (79.5%) (p < 0.001). There was a correlation between triage level and length of ED stay. The SPTS is a valid tool for use in the paediatric emergency setting. This was supported by strong performance in important patient outcomes, such as admission to hospital, ICU admissions and length of ED stay.

Decision support system for triage management: A hybrid approach using rule-based reasoning and fuzzy logic

ObjectivesFast and accurate patient triage for the response process is a critical first step in emergency situations. This process is often performed using a paper-based mode, which intensifies workload and difficulty, wastes time, and is at risk of human errors. This study aims to design and evaluate a decision support system (DSS) to determine the triage level. MethodsA combination of the Rule-Based Reasoning (RBR) and Fuzzy Logic Classifier (FLC) approaches were used to predict the triage level of patients according to the triage specialist’s opinions and Emergency Severity Index (ESI) guidelines. RBR was applied for modeling the first to fourth decision points of the ESI algorithm. The data relating to vital signs were used as input variables and modeled using fuzzy logic. Narrative knowledge was converted to If-Then rules using XML. The extracted rules were then used to create the rule-based engine and predict the triage levels. ResultsFourteen RBR and 27 fuzzy rules were extracted and used in the rule-based engine. The performance of the system was evaluated using three methods with real triage data. The accuracy of the clinical decision support systems (CDSSs; in the test data) was 99.44%. The evaluation of the error rate revealed that, when using the traditional method, 13.4% of the patients were miss-triaged, which is statically significant. The completeness of the documentation also improved from 76.72% to 98.5%. ConclusionsDesigned system was effective in determining the triage level of patients and it proved helpful for nurses as they made decisions, generated nursing diagnoses based on triage guidelines. The hybrid approach can reduce triage misdiagnosis in a highly accurate manner and improve the triage outcomes.