Triage Level Research Articles

Influence of the domestic COVID-19 pandemic on the pediatric emergency department.

ObjectivesAfter the coronavirus disease 2019 (COVID-19) pandemic emerged, there has been a substantial decline in emergency department (ED) visits. However, the impact of the pandemic on pediatric ED (PED) visits has not been well discussed. This study aimed to compare the epidemiology and clinical characteristics of PED visits before and after the time of the COVID-19 outbreak.MethodsData of pediatric patients admitted to the PED between February 2019 and January 2021 were retrospectively collected. All patients were divided into two groups: 1 year before the COVID-19 pandemic (group 1) and 1 year after the COVID-19 outbreak (group 2). Basic demographics, clinical characteristics, triage levels, categories of diagnosis at PED, disposition, and hospitalization rates (wards and intensive care units) were further analyzed and compared between the two groups.ResultsDuring the study period, 48,146 pediatric patients were enrolled (30,823 in group 1, and 17,323 in group 2). PED visits represented a 43.8% annual decline. The most common diseases in the PED in group 1 were infectious diseases, whereas digestive system diseases were the most common diseases in group 2 (both P < 0.001). In group 2, shorter PED observational time, longer hospital stay, and higher admission rates were noted compared to those in group 1 (all P < 0.001).ConclusionDuring the COVID-19 pandemic, the proportion of respiratory system diseases and infectious diseases sharply decreased in the PED, whereas the proportion of digestive system diseases relatively increased. The COVID-19 pandemic has impacted the nature of PED visits and we should pay more attention on digestive system diseases and the rates of out-of-hospital cardiac arrest and overall mortality.

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

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

The need for location-specific biometeorological indexes in Taiwan.

ObjectiveAs most available biometeorological indexes were developed decades ago in western countries, the benefit of using these indexes to study the effect of weather on human health in modern eastern countries is questionable. This study aimed to reconfirm the effectiveness of applying these biometeorological indexes when analyzing demand for daily emergency ambulance services (EAS) in Taipei.MethodsMore than 370,000 EAS usage records were analyzed in this study. The records were first allotted into different time-series data by age, gender, triage level, and case nature (trauma/non-trauma) in order to represent different kinds of daily EAS demand. They were then regressed on biometeorological indexes [Apparent Temperature (AT) and Net Effective Temperature (NET)]; the indexes' additional descriptive power to describe the daily EAS demand over traditional weather factors was then assessed.ResultsNo significant difference was observed in the descriptive powers in terms of effect on daily EAS demand of the biometeorological indexes and traditional weather factors. The largest improvement on the regression models' adjusted-R2 using NET and AT was only 0.008.ConclusionIt may not be a good idea to make direct use of the biometeorological indexes developed in western countries decades ago. Taiwan should have a tailor-made biometeorological index for a better representation of its unique situation.

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

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

Comparing the first and second waves of COVID-19 in a tertiary university hospital in Barcelona

Background: Hospitals have constituted the limiting resource of the healthcare systems for the management of the COVID-19 pandemic. As the pandemic progressed, knowledge of the disease improved, and healthcare systems were expected to be more adapted to provide a more efficient response. The objective of this research was to compare the flow of COVID-19 patients in emergency rooms and hospital wards, between the pandemic's first and second waves at the University Hospital of Vall d’Hebron (Barcelona, Spain), and to compare the profiles, severity and mortality of COVID-19 patients between the two waves. Methods: A retrospective observational analysis of COVID-19 patients attending the hospital from February 24 to April 26, 2020 (first wave) and from July 24, 2020, to May 18, 2021 (second wave) was carried out. We analysed the data of the electronic medical records on patient demographics, comorbidity, severity, and mortality. Results: The daily number of COVID-19 patients entering the emergency rooms (ER) dropped by 65% during the second wave compared to the first wave. During the second wave, patients entering the ER were significantly younger (61 against 63 years old p<0.001) and less severely affected (39% against 48% with a triage level of resuscitation or emergency; p<0.001). ER mortality declined during the second wave (1% against 2%; p<0.000). The daily number of hospitalised COVID-19 patients dropped by 75% during the second wave. Those hospitalised during the second wave were more severely affected (20% against 10%; p<0.001) and were referred to the intensive care unit (ICU) more frequently (21% against 15%; p<0.001). Inpatient mortality showed no significant difference between the two waves. Conclusions: Changes in the flow, severity and mortality of COVID-19 patients entering this tertiary hospital during the two waves may reflect a better adaptation of the health care system and the improvement of knowledge on the disease.

What Has Changed in Injury-Related Presentations During COVID-19 Pandemic? A Single-Center Experience from a Pediatric Emergency Department

Objective:The coronavirus disease 2019 pandemic affected the healthcare systems worldwide. In this study, we aimed to examine the impact of the coronavirus disease 2019 pandemic on injury-related visits.Materials and Methods:We conducted a retrospective analysis of 7648 injury-related pediatric emergency department visits between March 11 and June 30, 2018, 2019, and 2020, and compared the total number of visits, triage levels, distributions of injury mechanisms, and admission rates during the pandemic in 2020 to the same period in 2018 and 2019.Results:In the first 4 months of the pandemic, there was a 69.5% drop in all pediatric emergency department visits compared to the previous 2 years. Despite this decrease, the proportion of injury-related pediatric emergency department visits increased from 14% to 20.9% in 2020 (P < .001). There was a 3.8% increase in the frequencies of patients with high triage acuity levels (T1, T2, and T3) and a 3.8% decrease in patients with low triage acuity levels (P < .001). The domestic injury rate increased from 40% to 60% during the pandemic period (P < .001). Hospitalization rates increased from 6% to 11.5% and admission to intensive care units increased from 0.9% to 3.3%. The differences were statistically significant (P < .001). Visits due to burn increased from 2.7% to 5.2% (P < .001), poisoning from 3.4% to 5.5% (P < .001), bicycle accidents from 3.3% to 6.8% (P < .001), while injuries due to motor vehicle accidents decreased from 2.6% to 1.3% (P = .004) and sports injuries decreased from 8% to 2.1% (P < .001).Conclusion:This study revealed that despite the significant decrease in total pediatric emergency department visits, percentages of injury-related visits increased during the pandemic.

Educational intervention in triage with the Swedish triage scale RETTS©, with focus on specialist nurse students in ambulance and emergency care – A cross-sectional study

AimTo determine the reliability of application of the RETTS© triage scale after an educational intervention using paper-based scenarios in emergency care education. BackgroundKnowledge about and education in triage are important factors in triagescale implementation. Presenting students with a large number of triage scenarios is a common part of triage education. MethodsIn this prospective cross-sectional study at two universities students undergoing education in emergency care used RETTS© to assess triage level in 46 paper-based scenarios. Results57 students in the study made 2590 final triage decisions. Fleiss Kappa for final triage was 0.411 which is in the lower range of moderate agreement. In 25 of 46 (53.4%) scenarios, final triage levels did not agree about whether the case was stable or unstable. Conclusion/ImplicationsApplication of the RETTS© triage scale after an educational intervention with paper-based simulation in emergency care education resulted in moderate agreement about the final levels of triage.

Utility of National Early Warning Score 2 to risk-stratify coronavirus disease of 2019 patients in the emergency department: A retrospective cohort study.

The application of a risk stratification pathway is necessary for the emergency department (ED) to assess the severity of the disease and the need for escalation of therapy. We aimed to implement the National Early Warning Score 2 (NEWS2) pathway at triage to differentiate patients who are stable or critically ill with no invasive investigations at the time of admission during the coronavirus disease of 2019 (COVID-19) era in comparison to other clinical risk scores. One hundred and four patients were collected from April 1, 2021, to June 1, 2021, during the second wave of the COVID-19 pandemic at an academic medical center in India. The NEWS2 scoring system and the quick sepsis-related organ failure assessment (qSOFA) score were introduced as part of the initial assessment in the triage area of the ED. Data were assessed using the area under the receiving operating characteristic (AUROC) curve for NEWS2 and qSOFA scores, respectively. In the study, NEWS2 classification indicated that 25% of patients required continuous monitoring, of which 12.7% subsequently deteriorated within 24 h of admission and 7% died. Both, NEWS2 (threshold 0; 1, AUROC 0.883; 95%; confidence interval [CI] 0.8-0.966) and qSOFA (threshold 0; 1, AUROC 0.851; 95% CI 0.766-29 0.936) effectively identified COVID-19 patients in the ED at risk for clinical deterioration. There was no significant difference in the diagnostic performance of qSOFA and NEWS2 (DeLong's test P = 0.312). Both NEWS2 and qSOFA effectively-identified COVID-19 patients in the ED at risk for clinical deterioration with no significant statistical difference. However, a triage level risk stratification score can be developed with the inclusion of blood parameters on admission to further validate the practice.

Reliability and Validity of a New Computer-Based Triage Decision Support Tool: ANKUTRIAGE.

Triage is a tool used to determine patients' severity of illness or injury within minutes of arrival. This study aims to assess the reliability and validity of a new computer-based triage decision support tool, ANKUTRIAGE, prospectively. ANKUTRIAGE, a 5-level triage tool was established considering 2 major factors, patient's vital signs and characteristics of the admission complaint. Adult patients admitted to the ED between July and October, 2019 were consecutively and independently double triaged by 2 assessors using ANKUTRIAGE system. To measure inter-rater reliability, quadratic-weighted kappa coefficients (Kw) were calculated. For the validity, associations among urgency levels, resource use, and clinical outcomes were evaluated. The inter-rater reliability between users of ANKUTRIAGE was excellent with an agreement coefficient (Kw) greater than 0.8 in all compared groups. In the validity phase, hospitalization rate, intensive care unit admission and mortality rate decreased from level 1 to 5. Likewise, according to the urgency levels, resource use decreased significantly as the triage level decreased (P < 0.05). ANKUTRIAGE proved to be a valid and reliable tool in the emergency department. The results showed that displaying the key discriminator for each complaint to assist decision leads to a high inter-rater agreement with good correlation between urgency levels and clinical outcomes, as well as between urgency levels and resource consumptions.

Outcomes in patients not conveyed by emergency medical services (EMS): a one-year prospective study

BackgroundThe decision to not convey patients has become common in emergency medical services worldwide. A substantial proportion (12–51%) of the patients seen by emergency medical services are not conveyed by those services. The practice of non-conveyance is a result of the increasing and changing demands on the acute care system. Research focusing on the outcomes of the decision by emergency medical services to not convey patients is needed.AimThe aim was to describe outcomes (emergency department visits, admission to in-hospital intensive care units and mortality, all within seven days) and their association with the variables (sex, age, day of week, time of day, emergency signs and symptoms codes, triage level colour, and destination) for non-conveyed patients.MethodsThis was a prospective analytical study with consecutive inclusion of all patients not conveyed by emergency medical services. Patients were included between February 2016 and January 2017. The study was conducted in Region Örebro county, Sweden. The region consists of both rural and urban areas and has a population of approximately 295,000. The region had three ambulance departments that received approximately 30,000 assignments per year.ResultsThe result showed that no patient received intensive care, and 18 (0.7%) patients died within seven days after the non-conveyance decision. Older age was associated with a higher risk of hospitalisation and death within seven days after a non-conveyance decision.ConclusionsBased on the results of this one-year follow-up study, few patients compared to previous studies were admitted to the hospital, received intensive care or died within seven days. This study contributes insights that can be used to improve non-conveyance guidelines and minimise the risk of patient harm.

A trilogy to understand: adrenalin, allergy and anaphylaxis

Allergy, anaphylaxis and adrenaline are three closely related terms in medicine. Upon identification or suspicion of anaphylaxis, adrenaline should be administered as soon as possible. An allergy can be characterised by anything from a simple skin rash to severe vital parameter abnormalities. The role of the reception nurse will be first to identify clinically relevant features, to assign the right level of triage to the patient and adjust the care pathway.

Comparison of outcomes in emergency department revisiting patients before and after coronavirus disease 2019 epidemic.

The outbreak of COVID-19 challenged the global health system and specifically impacted the emergency departments (EDs). Studying the quality indicators of ED care under COVID-19 has been a necessary task, and ED revisits have been used as an indicator to monitor ED performance. The study investigated whether discrepancies existed among ED revisiting cases before and after COVID-19 and whether the COVID-19 epidemic was a predictor of poor outcomes of ED revisits. Retrospective study. We used electronic health records data from a tertiary medical center. Data of patients with 72-h ED revisit after the COVID-19 epidemic were collected from February 2020 to June 2020 and compared with those of patients before COVID-19, from February 2019 to June 2019. The investigated outcomes included hospital admission, ICU admission, out-of-hospital cardiac arrest, and subsequent inhospital mortality. Univariate and multivariate logistic regression models were used to identify independent predictors of 72-h ED revisit outcomes. In total, 1786 patients were enrolled in our study - 765 in the COVID group and 1021 in the non-COVID group. Compared with the non-COVID group, patients in the COVID group were younger (53.9 vs. 56.1 years old; P = 0.002) and more often female (66.1% vs. 47.3%; P < 0.001) and had less escalation of triage level (11.6% vs. 15.0%; P = 0.041). The hospital admission and inhospital mortality rates in the COVID and non-COVID groups were 33.9% vs. 32.0% and 2.7% vs. 1.5%, respectively. In the logistic regression model, the COVID-19 period was significantly associated with inhospital mortality (adjusted odds ratio, 2.289; 95% confidence interval, 1.059-4.948; P = 0.035). Patients with 72-h ED revisits showed distinct demographic and clinical patterns before and after the COVID-19 epidemic; the COVID-19 period was an independent predictor of increased inhospital mortality.

Machine learning–based triage to identify low-severity patients with a short discharge length of stay in emergency department

BackgroundOvercrowding in emergency departments (ED) is a critical problem worldwide, and streaming can alleviate crowding to improve patient flows. Among triage scales, patients labeled as “triage level 3” or “urgent” generally comprise the majority, but there is no uniform criterion for classifying low-severity patients in this diverse population. Our aim is to establish a machine learning model for prediction of low-severity patients with short discharge length of stay (DLOS) in ED.MethodsThis was a retrospective study in the ED of China Medical University Hospital (CMUH) and Asia University Hospital (AUH) in Taiwan. Adult patients (aged over 20 years) with Taiwan Triage Acuity Scale level 3 were enrolled between 2018 and 2019. We used available information during triage to establish a machine learning model that can predict low-severity patients with short DLOS. To achieve this goal, we trained five models—CatBoost, XGBoost, decision tree, random forest, and logistic regression—by using large ED visit data and examined their performance in internal and external validation.ResultsFor internal validation in CMUH, 33,986 patients (75.9%) had a short DLOS (shorter than 4 h), and for external validation in AUH, there were 13,269 (82.7%) patients with short DLOS. The best prediction model was CatBoost in internal validation, and area under the receiver operating cha racteristic curve (AUC) was 0.755 (95% confidence interval (CI): 0.743–0.767). Under the same threshold, XGBoost yielded the best performance, with an AUC value of 0.761 (95% CI: 0.742- 0.765) in external validation.ConclusionsThis is the first study to establish a machine learning model by applying triage information alone for prediction of short DLOS in ED with both internal and external validation. In future work, the models could be developed as an assisting tool in real-time triage to identify low-severity patients as fast track candidates.

Using mobility status as a frailty indicator to improve the accuracy of a computerised five-level triage system among older patients in the emergency department

BackgroundOwing to societal ageing, the number of older individuals visiting emergency departments (EDs) has increased in recent years. For this patient population, accurate triage systems are required. This retrospective cohort study assessed the accuracy of a computerised five-level triage system, the Taiwan Triage and Acuity System (TTAS), by determining its ability to predict in-hospital mortality in older adult patients and compare it with the corresponding rate in younger adult patients presenting to EDs. The association between frailty, which the current triage system does not consider, was also investigated.MethodsThe medical records of adult patients admitted to a single ED between 2016 and 2017 were reviewed. Data collected included information on demographics, triage level, frailty status, in-hospital mortality, and medical resource utilisation. The patients were divided into four age groups: two older adult groups (older: 65–84 years and very old: ≥85 years) and two younger adult groups (young: 18–39 and middle-aged: 40–64 years).ResultsOur study included 265,219 ED adult patients, of whom 64,104 and 16,009 were in the older and very old groups, respectively. The in-hospital mortality rate at each triage level increased with age. The ability of the TTAS to predict in-hospital mortality decreased with age (area under the receiver operating characteristic curve [AUROC]: young: 0.86; middle-aged, 0.84; and older and very old: 0.79). Frailty was associated with in-hospital mortality (odds ratio, 2.20; 95% confidence interval, 2.03–2.38). Adding mobility status as a frailty indicator to TTAS only slightly improved its ability to predict in-hospital mortality (AUROC: 0.74–0.77) in patients ≥65 years of age.ConclusionsThe ability of the current triage system to predict in-hospital mortality decreases with age. Although frailty as mobility was associated with in-hospital mortality, its addition to the TTAS only slightly improved the accuracy with which in-hospital mortality in older patients presenting to EDs was predicted.

Evaluation of the Validity and Reliability of ANKUTRIAGE, a New Decision Support System in Pediatric Emergency Triage.

The intensity of emergency services is an increasing health problem all over the world, necessitating an effective triage system. The aim of this study was to evaluate the validity and reliability of the "ANKUTRIAGE" in children. This prospective, longitudinal study was carried out at a pediatric emergency department. ANKUTRIAGE, a 5-level computer-aided triage decision support system, was developed. Patients younger than 18 years who do not need emergency intervention, who had complete vital sign measurements, who gave consent for the study, and who were admitted to the emergency service during working hours with trained personnel were included. For validity, agreement between the urgency levels determined by ANKUTRIAGE and the reference triage systems: Pediatric Canadian Triage and Acuity Scale and Emergency Severity Index, was evaluated. In addition, the association of urgency levels with clinical outcomes was studied. To assess reliability, patients were evaluated by 2 blinded healthcare professionals using ANKUTRIAGE and a quadratic weighted κ was estimated. A total of 1232 children with a median age of 4.00 years were included. ANKUTRIAGE acuity levels significantly correlated with the number of resources used, the number of patients undergoing life-saving procedures, pediatric intensive care unit, and overall hospitalization rates, respectively ( P < 0.001, P < 0.001, P < 0.001, P < 0.001). The agreement of ANKUTRIAGE with Pediatric Canadian Triage and Acuity Scale was found to be 0.94 (95% confidence interval [CI], 0.93-0.94), with an Emergency Severity Index of 0.75 (95% CI, 0.70-0.80). The interrater agreement between 2 evaluators who used ANKUTRIAGE reflected as excellent consistency 0.92 (95% CI, 0.89-0.95; κ > 0.8). ANKUTRIAGE demonstrated high agreement with clinical outcomes and with proven triage systems and reflected high reliability between users. ANKUTRIAGE will enable a more standardized and practical triage, especially in crowded pediatric emergency departments and in situations where triage is performed by health professionals with different experience and professions.

Sex and Race Differences in the Evaluation and Treatment of Young Adults Presenting to the Emergency Department With Chest Pain.

BackgroundAcute myocardial infarctions are increasingly common among young adults. We investigated sex and racial differences in the evaluation of chest pain (CP) among young adults presenting to the emergency department.Methods and ResultsEmergency department visits for adults aged 18 to 55 years presenting with CP were identified in the National Hospital Ambulatory Medical Care Survey 2014 to 2018, which uses stratified sampling to produce national estimates. We evaluated associations between sex, race, and CP management before and after multivariable adjustment. We identified 4152 records representing 29 730 145 visits for CP among young adults. Women were less likely than men to be triaged as emergent (19.1% versus 23.3%, respectively, P<0.001), to undergo electrocardiography (74.2% versus 78.8%, respectively, P=0.024), or to be admitted to the hospital or observation unit (12.4% versus 17.9%, respectively, P<0.001), but ordering of cardiac biomarkers was similar. After multivariable adjustment, men were seen more quickly (hazard ratio [HR], 1.15 [95% CI, 1.05–1.26]) and were more likely to be admitted (adjusted odds ratio, 1.40 [95% CI, 1.08–1.81]; P=0.011). People of color waited longer for physician evaluation (HR, 0.82 [95% CI, 0.73–0.93]; P<0.001) than White adults after multivariable adjustment, but there were no racial differences in hospital admission, triage level, electrocardiography, or cardiac biomarker testing. Acute myocardial infarction was diagnosed in 1.4% of adults in the emergency department and 6.5% of admitted adults.ConclusionsWomen and people of color with CP waited longer to be seen by physicians, independent of clinical features. Women were independently less likely to be admitted when presenting with CP. These differences could impact downstream treatment and outcomes.

Workload in Emergency Rooms among Clinical Specialties and Overburdened Neurologists

Background: To evaluate workload in emergency rooms (ERs) among clinical specialties including neurology and investigate characteristics of neurological consultations in ER.Methods: A nationwide survey was conducted to evaluate the number of specialists, resident physicians/surgeons, and emergency consultations of each clinical specialty in Korean tertiary referral hospitals from 2018 to 2019. Characteristics of neurological emergency consultations during the same period were investigated in one of the hospitals that participated.Results: A total of 23 hospitals were included. Four irrelevant clinical specialties were excluded. The number of neurology specialists and resident physicians were 12.5/hospital (4.1% of all specialists) and 6.4/hospital (3.4% of all resident physicians/surgeons), respectively, while the mean numbers of specialists and resident physicians or surgeons per clinical specialty were 13.7/hospital and 8.6/hospital, respectively. Neurological consultations accounted for 11.0% of all ER consultations for severe patients (Korean Triage and Acuity Scale level 1-3). Annual ER consultations for severe patients per neurology specialist was 274.1, which was only second to pediatrics (290.0). Annual ER consultations for severe patients per resident physician was 406.6 which was 1.6 times higher than the second highest (internal medicine, 247.0). Frequent conditions for neurological ER consultation were dizziness (24.8%), motor weakness (23.9%), headache (10.6%), dysarthria (9.9%), and seizures (7.7%). Frequent primary diagnoses were cerebrovascular diseases (29.0%) and episodic and paroxysmal disorders (24.9%).Conclusions: Workloads of neurology specialists for ER consultation were significantly heavy, and the workload of neurology resident physicians was the heaviest among all specialties. This should be considered in health care policies.

Validation of the Computerized Pediatric Triage Tool, pediaTRI, in the Pediatric Emergency Department of Lenval Children's Hospital in Nice: A Cross-Sectional Observational Study.

IntroductionA reliable pediatric triage tool is essential for nurses working in pediatric emergency departments to quickly identify children requiring priority care (high-level emergencies) and those who can wait (low-level emergencies). In the absence of a gold standard in France, the objective of our study was to validate our 5-level pediatric triage tool –pediaTRI– against the reference tool: the Pediatric Early Warning Score (PEWS) System.Materials and MethodsWe prospectively included 100,506 children who visited the Pediatric Emergency Department at Lenval Children's Hospital (Nice, France) in 2016 and 2017. The performance of pediaTRI to identify high-level emergencies (severity levels 1 and 2) was evaluated in comparison with a PEWS ≥ 4/9. Data from 2018–19 was used as an independent validation cohort.ResultspediaTRI agreed with the PEWS score for 84,896 of the patients (84.5%): 15.0% (14.8–15.2) of the patients were over-triaged and 0.5% (0.5–0.6) under-triaged compared with the PEWS score. pediaTRI had a sensitivity of 76.4% (74.6–78.2), a specificity of 84.7% (84.4–84.9), and positive and negative likelihood ratios of 5.0 (4.8–5.1) and 0.3 (0.3–0.3), respectively, for the identification of high-level emergencies. However, the positive likelihood ratios were lower for patients presenting with a medical complaint [4.1 (4.0–4.2) v 10.4 (7.9–13.7 for trauma), and for younger children [1.2 (1.1–1.2) from 0 to 28 days, and 1.9 (1.8–2.0) from 28 days to 3 months].ConclusionpediaTRI has a moderate to good validity to triage children in a Pediatric Emergency Department with a tendency to over-triage compared with the PEWS system. Its validity is lower for younger children and for children consulting for a medical complaint.

Cumplimentación de la escala qSOFA en el triaje de urgencias

Objective: Analyze the diagnostic precision of the qSOFA scale against the SIRS criteria in emergency triage to identify patients with suspected sepsis. Method: Ambispective cohort study in the emergency room of the Costa del Sol Hospital. The study subjects were older than 14 years who attended with suspected or confirmed infection in the years 2017 and 2019. Sociodemographic variables were evaluated, the physiological variables of qSOFA and SIRS, level of triage, attention circuit, activation of sepsis code. Descriptive analysis was performed in a segmented manner according to the year of study. The statistics of the diagnostic tests were described to know the prognostic capacity of qSOFA. Results: 42 patients were recruited in 2017 and 41 in 2019.The mean age of the patients exceeded 75 years on average in both periods. When analyzing the diagnostic effort for activating the sepsis code, 2 patients (4.8%) had completed all the parameters contemplated by SIRS and 1 (2.4%) with qSOFA (p = 1) for each year of study. Conclusions: The lack of records of physiological parameters that contemplate the study scales has made it difficult to determine the diagnostic validity of qSOFA in hospital emergencies. However, the experience and clinical judgment of the triage nurse has contributed to the fact that all the patients studied were correctly classified according to the level of priority and care circuit, guaranteeing early care in sepsis.

Are 5-level triage systems improved by using a symptom based approach?\u2014a Danish cohort study

BackgroundFive-level triage systems are being utilized in Danish emergency departments with and without the use of presenting symptoms. The aim of this study was to validate and compare two 5-level triage systems used in Danish emergency departments: “Danish Emergency Process Triage” (DEPT) based on a combination of vital signs and presenting symptoms and a locally adapted version of DEPT (VITAL-TRIAGE) using vital signs only.MethodsThis was a retrospective cohort using data from five Danish emergency departments. All patients attending an emergency department during the period of 1 April 2012 until 31 December 2015 were included. Validity of the two triage systems was assessed by comparing urgency categories determined by each triage system with critical outcomes: admission to Intensive care unit (ICU) within 24 h, 2-day mortality, diagnosis of critical illness, surgery within 48 h, discharge within 4 h and length of hospital stay.ResultsWe included 632,196 ED contacts. Sensitivity for 24-h ICU admission was 0.79 (95% confidence interval 0.78–0.80) for DEPT and 0.44 (0.41–0.47) for VITAL-TRIAGE. The sensitivity for 2-day mortality was 0.69 (0.67–0.70) for DEPT and 0.37 (0.34–0.41) for VITAL-TRIAGE. The sensitivity to detect diagnoses of critical illness was 0.48 (0.47–0.50) for DEPT and 0.09 (0.08–0.10) for VITAL-TRIAGE. The sensitivity for predicting surgery within 48 h was 0.30 (0.30–0.31) in DEPT and 0.04 (0.04–0.04) in VITAL-TRIAGE. Length of stay was longer in VITAL-TRIAGE than DEPT. The sensitivity of DEPT to predict patients discharged within 4 h was 0.91 (0.91–0.92) while VITAL-TRIAGE was higher at 0.99 (0.99–0.99). The odds ratio for 24-h ICU admission and 2-day mortality was increased in high-urgency categories of both triage systems compared to low-urgency categories.ConclusionsHigh urgency categories in both triage systems are correlated with adverse outcomes. The inclusion of presenting symptoms in a modern 5-level triage system led to significantly higher sensitivity measures for the ability to predict outcomes related to patient urgency. DEPT achieves equal prognostic performance as other widespread 5-level triage systems.